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照護管理 · MEDIUM · MCQ

急診檢傷護理師評估同時湧入的重症病患。根據急診檢傷優先順序,哪位病患必須強制佔據絕對的第一臨床介入?

An ER triage nurse evaluates an influx of critical clients arriving simultaneously. According to emergency triage priority, which client must powerfully mandate the absolute first clinical intervention?

  • AA client displaying an extensive mid-shaft femur fracture crying aggressively for massive pain relief.
    一位顯示中段股骨骨折並因劇痛而憤怒哭喊的病患。
  • BA client clutching their right upper abdomen exactly reporting sharp continuous pain upon palpation.
    一位緊抓右上腹部並明確報告觸診時有尖銳持續疼痛的病患。
  • CA client displaying paradoxical asynchronous chest wall movement and massive severe dyspnea.✓ 正解
    一位顯示矛盾性非同步胸壁運動及嚴重呼吸困難的病患。
  • DA client accurately presenting with chronic heart failure requiring continuous IV diuretic therapy.
    一位準確呈現需要持續靜脈注射利尿劑治療之慢性心臟衰竭的病患。
Explanation · 中文詳解

本題再次穩固 ABC 創傷法規。選項 C 是連枷胸 (Flail Chest),特徵為『反向胸壁運動 (Paradoxical chest wall movement)』。吸氣時胸壁凹下去,代表肋骨斷了好幾根,肺部不僅無法充氣,還有被刺穿血胸的危險。它屬於 Airway/Breathing 等級的立即致死崩潰,遠大於骨折(A) 或器官痛(B)。

This question again reinforces the ABC trauma principles. Option C describes flail chest, characterized by paradoxical chest wall movement: during inspiration, the chest wall moves inward, indicating multiple rib fractures, with the lungs unable to expand and a risk of being punctured causing hemothorax. This is an immediately life-threatening problem at the Airway/Breathing level, far exceeding fracture (A) or organ pain (B).

✦ 台美臨床差異

Flail chest (連枷胸) 的反常呼吸 (Paradoxical movement) 是 NCLEX 必考字眼,看到秒選 D (Airway)。

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