外科病房護理師評估湧入的創傷出血病患。哪一位病患要求最第一的快速臨床介入？
A surgical unit nurse evaluates a sudden influx of bleeding trauma clients. Which client demands the very first rapid clinical intervention?
- AA client possessing a gaping jagged right forearm laceration securely packed.右前臂有嚴重撕裂傷且已妥善填塞包紮
- BA client 1 hour post-closed-reduction of a dislocated left shoulder.左肩脫臼閉合復位後 1 小時
- CA client presenting with a simple closed right tibial fracture.單純右脛骨閉鎖性骨折
- DA client displaying an extensive mid-shaft femur fracture with a board-like rigid abdomen.✓ 正解廣泛性股骨中段骨折伴隨板狀僵硬腹部
這道題目旨在測試護理師在創傷出血病患中，快速識別最危急情況並確立優先介入的能力。在創傷護理中，評估和處理生命威脅是最高優先。當病患出現腹部板狀僵硬（board-like rigid abdomen）伴隨股骨中段骨折時，腹部板狀僵硬是腹腔內出血或腹膜炎的典型徵象，這代表可能存在大量內出血，導致休克甚至死亡。股骨骨折本身也會導致大量失血，但腹部僵硬的徵象提示更廣泛且可能更急迫的內出血。因此，處理內出血以穩定循環是首要任務，這符合ABC（Airway, Breathing, Circulation）原則中的循環（Circulation）優先。
This question tests the nurse's ability to rapidly identify the most critical condition in a trauma patient with hemorrhage and to establish priority intervention. In trauma nursing, the evaluation and management of life-threatening conditions takes the highest priority. When a patient presents with a board-like rigid abdomen accompanied by a midshaft femoral fracture, the board-like rigid abdomen is a hallmark sign of intra-abdominal hemorrhage or peritonitis, indicating potentially massive internal bleeding that may lead to shock or even death. While a femoral fracture itself can also cause substantial blood loss, abdominal rigidity suggests more extensive and potentially more urgent internal hemorrhage. Therefore, managing internal bleeding to stabilize circulation is the primary task, consistent with the circulation priority under the ABC (Airway, Breathing, Circulation) principle.
在台灣和美國，創傷病患的緊急處理原則都是以ABCDE（Airway, Breathing, Circulation, Disability, Exposure）評估為核心。腹部板狀僵硬在兩地都被視為腹腔內嚴重問題（如內出血、腹膜炎）的危急徵象，需立即處理。對於創傷病患，快速建立靜脈通路、液體復甦、止血和準備手術介入是共通的臨床實務。NCLEX強調護理師在多重創傷病患中快速判斷最危急狀況的能力。