— 降低風險 · MEDIUM · MCQ —
護理師準備對一位疑似腦膜炎的病人進行身體評估，應優先採取哪項措施？
A nurse is preparing to perform a physical assessment on a client with suspected meningitis. Which action should the nurse implement first?
- AAssess for nuchal rigidity評估頸部僵硬
- BAdminister an antipyretic給予解熱劑
- CPlace the client on droplet precautions✓ 正解將病人實施飛沫隔離
- DPerform the Kernig's sign test進行 Kernig 徵象測試
— Explanation · 中文詳解 —
腦膜炎（meningitis）具有高傳染性，採取防護措施是保護環境安全的首要任務。依據感染控制標準，對於疑似腦膜炎病人，應在診斷確認前立即實施飛沫隔離（droplet precautions），以切斷傳播途徑。這符合 NCLEX 的安全優先級（Safety/Infection Control）原則。
Because meningitis is highly contagious, initiating droplet precautions is the priority action to protect healthcare workers and other patients from transmission. Infection control measures take precedence over physical assessment techniques like checking for nuchal rigidity or performing Kernig's sign.
✦ 台美臨床差異
美國醫院針對疑似腦膜炎（尤其是腦膜炎雙球菌）的隔離執行非常嚴格，護理師在接獲醫囑前，通常依據急診檢傷分類（Triage）流程即可先行啟動隔離措施。