— 照護管理 · MEDIUM · MCQ —
護理師在交班後進行護理優先順序評估。哪位病人需最優先評估？
The nurse is prioritizing care at the start of the shift. Which client should the nurse assess first?
- AA client with a new onset of sudden confusion and restlessness✓ 正解新發突發意識混亂與躁動的病人
- BA client awaiting discharge papers for home等待出院文件回家的病人
- CA client post-operative day one complaining of incisional pain術後第一天抱怨切口疼痛的病人
- DA client with type 2 diabetes requesting a blood glucose check要求測量血糖的第二型糖尿病病人
— Explanation · 中文詳解 —
根據 ABC 原則與危急程度，神智改變（confusion）伴隨不安（restlessness）通常是缺氧、腦部灌流不足或敗血症的前兆，屬危急狀態。A 可由輔助人員協助，C 為常見術後反應，B 則為行政作業。C 若不儘速排除潛在致命原因，可能迅速演變為呼吸衰竭或休克。
By the ABC principle and severity of the situation, an altered mental status (confusion) accompanied by restlessness is often an early sign of hypoxia, cerebral hypoperfusion, or sepsis and is critical. Option D can be handled with assistive personnel, C is a common postoperative reaction, and B is administrative. Without prompt action to rule out the underlying life-threatening cause, option A may rapidly progress to respiratory failure or shock.
✦ 台美臨床差異
美國護理師在確認突發意識變更時，常需立即啟動快速反應小組（RRT）；台灣多先評估後通知醫師，流程相似但組織反應速度略有差異。