— 生理適應 · HARD · MCQ —
一位頭部受傷的病患出現耳部流出澄清液體。護理師的首要行動為何？
A client with a head injury exhibits clear fluid draining from the ear. What is the nurse's priority action?
- ATurn the client onto the side of the drainage將病人轉向引流側
- BCheck the drainage for glucose✓ 正解檢查引流液的葡萄糖含量
- CNotify the physician immediately立即通知醫師
- DPack the ear with gauze用紗布填塞耳朵
— Explanation · 中文詳解 —
耳部流出澄清液體強烈懷疑為腦脊髓液 (CSF) 外漏。護理師應先測試液體是否含有葡萄糖，因為 CSF 含有葡萄糖。D 選項會導致感染並增加顱內壓，絕對禁止。C 與 A 雖然是後續動作，但在確定是 CSF 之前，測試是關鍵鑑別診斷。
Clear fluid draining from the ear strongly suggests cerebrospinal fluid (CSF) leakage. The nurse should first test the drainage for glucose, because CSF contains glucose. Option D would cause infection and increase intracranial pressure and is absolutely contraindicated. Options C and A are subsequent actions, but until CSF is confirmed, glucose testing is the key step for differential diagnosis.
✦ 台美臨床差異
美台對 CSF 外漏的處理原則一致：絕對禁止填塞，皆需保持引流通暢。