病人懷疑脊髓損傷入院。護理師應評估的最高優先級是什麼？
A patient is admitted with a suspected spinal cord injury. Which is the highest priority for the nurse to assess?
- ABladder distension膀胱脹滿
- BSkin integrity皮膚完整性
- CRange of motion關節活動度
- DRespiratory pattern✓ 正解呼吸模式
脊髓損傷（SCI）的優先級評估應遵循 ABC 原則（Airway, Breathing, Circulation）。高位脊髓損傷（C3-C5）會導致橫膈膜麻痺，導致呼吸衰竭，這是導致死亡的最主要原因。因此，呼吸模式（Respiratory pattern）與呼吸頻率是所有評估中最優先的項目。 bladder、皮膚與關節活動度雖重要，但屬於穩定後的二級護理項目。
Priority assessment in spinal cord injury (SCI) follows the ABC principle (Airway, Breathing, Circulation). High cervical injuries (C3-C5) can paralyze the diaphragm, causing respiratory failure, which is the leading cause of death in this population. Respiratory pattern and rate are therefore the most important parameters to assess. Bladder distension, skin integrity, and range of motion are important but are secondary nursing concerns to be addressed after stabilization.