— 生理適應 · HARD · MCQ —
一位病患術後 6 小時進行甲狀腺切除術。下列哪項表現需要護理師立即介入？
A nurse is caring for a client who had a thyroidectomy 6 hours ago. Which manifestation requires immediate nursing intervention?
- ANumbness around the mouth口周麻木
- BBilateral laryngeal stridor✓ 正解雙側喉鳴音
- CHoarseness when speaking說話時聲音沙啞
- DPain at the incision site切口處疼痛
— Explanation · 中文詳解 —
甲狀腺切除術（Thyroidectomy）後，護理師需高度警覺呼吸道併發症。喉頭喘鳴音（Laryngeal stridor）是氣道阻塞的危急徵兆，可能源於術後血腫壓迫、喉頭水腫或因手術損傷喉返神經（Recurrent laryngeal nerve）導致聲帶麻痺。根據 ABC（Airway, Breathing, Circulation）護理原則，氣道安全是首要優先級，發現此症狀應立即通知醫師準備氣管插管或緊急氣切（Tracheostomy）。
Bilateral laryngeal stridor is a medical emergency indicating airway obstruction, which can result from postoperative hematoma compression or laryngeal edema. According to ABC priorities, securing the airway is the immediate nursing responsibility, whereas hoarseness and mild pain are expected findings.