— 照護管理 · HARD · MCQ —
護理師照護一組病人，下列哪位病人需要立即評估以預防致命風險？
A nurse is responsible for a group of clients. Which client requires immediate assessment to prevent a life-threatening situation?
- AA client with a history of hypertension requesting pain medication有高血壓病史並要求止痛藥的病人
- BA client with a blood pressure of 130/85 mmHg血壓為 130/85 mmHg 的病人
- CA client with a new onset of hoarseness following thyroidectomy✓ 正解甲狀腺切除術後出現新發聲音嘶啞的病人
- DA client with a surgical drain leaking small amount of serosanguineous fluid手術引流管滲出少量漿液血性液體的病人
— Explanation · 中文詳解 —
甲狀腺切除術後若出現聲音嘶啞（hoarseness），可能暗示喉返神經受損或局部出血引發氣管壓迫，這是危及氣道的徵象，必須立即處理（C）。其餘選項中，引流液量少屬預期狀況，血壓在臨界範圍內，疼痛需求雖重要但非致命性呼吸道危機。
New-onset hoarseness following a thyroidectomy is a critical sign that may indicate laryngeal edema or hemorrhage compressing the airway. This potential airway compromise requires immediate assessment, whereas stable vital signs, expected drainage, and non-life-threatening pain are lower priorities.
✦ 台美臨床差異
這類術後併發症評估在台美皆屬護理師的核心臨床警戒能力。