一位 55 歲患有高血壓的客戶主訴突發性「壓迫感」胸痛並放射至左手臂。護理師應優先採取何種介入措施？
A 55-year-old client with a history of hypertension reports a sudden onset of 'crushing' chest pain radiating to the left arm. Which intervention should the nurse prioritize?
- ATeach the client about stress management教導客戶壓力管理
- BAssess the client's blood pressure評估客戶的血壓
- CAdminister morphine sulfate給予硫酸嗎啡
- DObtain a 12-lead electrocardiogram (ECG)✓ 正解取得十二導程心電圖 (ECG)
突發性胸痛且有放射痛，屬於急性冠心症（ACS）的高風險表現。護理師的首要任務是進行診斷性評估，以決定後續處置。12 導程心電圖（D）是判斷是否有 ST 波段抬高（STEMI）的關鍵，若為 STEMI，必須在黃金時間內進行再灌注治療（如 PCI）。 morphine（C）雖可用於緩解疼痛，但其優先級低於診斷與心肌再灌注的評估。血壓（B）測量雖也是評估的一部分，但心電圖對急性心肌梗塞的診斷價值更高。
Sudden crushing chest pain radiating to the arm suggests acute coronary syndrome, where rapid diagnosis is critical for guiding life-saving interventions. A 12-lead electrocardiogram (ECG) is the priority assessment to determine if ST-segment elevation myocardial infarction (STEMI) is present, which dictates the need for immediate reperfusion therapy. While pain management and vital signs are important, obtaining the ECG takes precedence to ensure timely treatment.