— 照護管理 · HARD · MCQ —
交班後，護理師應優先評估哪位病人？
Which client should the nurse see first after receiving the change-of-shift report?
- AA client requesting a refill for their water pitcher要求補充水瓶的病人
- BA client experiencing new onset of confusion and restlessness✓ 正解出現新發意識混亂與煩躁不安的病人
- CA client with a stable post-operative incision that needs dressing change術後傷口穩定但需換藥的病人
- DA client with a scheduled medication due in 30 minutes30分鐘後需按時給藥的病人
— Explanation · 中文詳解 —
根據 ABC 原則與急迫性（Priority Setting），新的神經學變化（意識混亂與躁動）通常暗示急性缺氧、低血糖或神經損傷，是優先級最高的急症。給藥與敷料更換雖重要，但非急性變化，補水則屬於非緊急服務。
A client exhibiting new-onset confusion and restlessness requires immediate assessment, as these acute mental status changes may indicate a medical emergency such as hypoxia, hypoglycemia, or neurological compromise. This takes priority over routine tasks like dressing changes, scheduled medications, or non-urgent requests for water.
✦ 台美臨床差異
美台護理臨床決策的核心皆為病人安全與生命徵象穩定度，急症優先原則無異。