— 生理適應 · HARD · MCQ —
護理師照護一位 C4 頸椎損傷的患者，下列哪項護理問題最優先？
A nurse is caring for a client with a cervical spinal cord injury at the C4 level. What is the highest priority nursing concern?
- AImbalanced nutrition營養失衡
- BRisk for impaired skin integrity皮膚完整性受損風險
- CImpaired physical mobility身體活動能力受損
- DIneffective airway clearance✓ 正解無效的呼吸道清理
— Explanation · 中文詳解 —
頸椎 C4 受損會影響膈神經（Phrenic nerve）功能，可能導致呼吸肌麻痺或無力，造成呼吸功能衰竭。ABC 原則是護理的第一優先順序，呼吸道的通暢與換氣功能對 C4 損傷患者是生命攸關的關鍵。皮膚完整性、營養與活動受限雖重要，但皆屬次要護理重點。
Injury at the C4 cervical level affects the function of the phrenic nerve and can cause paralysis or weakness of the respiratory muscles, leading to respiratory failure. The ABC principle places airway and breathing first; in C4 injury, maintaining a patent airway and adequate ventilation is critical to survival. Skin integrity, nutrition, and limited mobility are important but are secondary nursing priorities.
✦ 台美臨床差異
美國脊髓損傷護理強調早期呼吸治療介入與復健醫療銜接；台灣在急性期多由 ICU 團隊處理，長期復健資源相對集中。