對於一位穿戴長腿石膏的病人，哪項評估結果需要護理師立即介入？
Which assessment finding in a client with a long-leg cast requires immediate intervention by the nurse?
- AThe client requires more opioid analgesics than 6 hours ago✓ 正解病人比 6 小時前需要更多的鴉片類鎮痛劑
- BThe client reports itching under the cast病人報告石膏下有搔癢感
- CThe toes are cool to the touch but pink in color腳趾觸摸起來冰冷但顏色呈粉紅色
- DThere is a small amount of serosanguinous drainage on the cast石膏上有少量漿液血性滲出液
核心概念：腔室症候群（Compartment Syndrome）的早期識別。這是骨折石膏固定後最危險的併發症。為何正確答案對：疼痛在給予止痛藥後仍加劇，或是疼痛程度與受傷比例不符，是腔室症候群的最早徵兆（Pain out of proportion）。為何其他選項錯：A 是常見不適；C 雖然腳涼但顏色紅潤（Pink），血循尚可，需持續觀察；D 若是術後少量滲液通常是預期內的。臨床思路：護理師必須具備「預見危急併發症」的能力，在神經血管受損不可逆（如無脈搏）之前，就應從疼痛性質的改變中察覺異狀並立即處理。
Core concept: Early identification of compartment syndrome. This is the most dangerous complication after fracture immobilization in a cast. Why the correct answer is right: Pain that worsens despite analgesics, or pain disproportionate to the injury, is the earliest sign of compartment syndrome (pain out of proportion). Why the other options are wrong: B is common discomfort; C is borderline (cool toes but pink color indicating adequate circulation, requiring continued observation); D is typically expected if it is a small amount of postoperative serosanguinous drainage. Clinical reasoning: The nurse must be able to anticipate critical complications and detect abnormalities through changes in the character of pain before neurovascular damage becomes irreversible (such as absent pulse) and intervene immediately.
美國 NCLEX 強調 6P（Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia），其中疼痛是首要。台灣臨床有時過度依賴脈搏（Pulselessness），但脈搏消失通常已是末期，需強調疼痛評估的重要性。