一位腦部外傷病人鼻部流出大量澄清液體。護理師應首要採取哪項行動？
A client with a head injury has a large amount of clear drainage from the nose. Which action should the nurse take first?
- AAsk the client to blow their nose要求病人捏鼻鼓氣
- BTest the drainage for glucose✓ 正解檢測引流液的葡萄糖含量
- CPlace the client in Trendelenburg position將病人置於垂頭仰臥位
- DPack the nose with sterile gauze用無菌紗布填塞鼻子
腦部外傷病人鼻部流出澄清液體，應高度懷疑是顱底骨折（Basilar skull fracture）導致的腦脊髓液（CSF）漏。CSF 含有葡萄糖，而一般的鼻涕（Mucus）則不含。因此，檢測液體中的葡萄糖含量是快速初步鑑別的方法。臨床思路上，若確認為 CSF 漏，護理師應立即通知醫師，並嚴禁病人擤鼻涕（避免顱內壓改變或細菌逆行感染）。安全（Safety）是核心，護理師應讓病人臥床休息並抬高床頭。若液體混有血液，則應觀察「光環徵象（Halo sign）」。
Clear nasal drainage after head trauma suggests a possible cerebrospinal fluid (CSF) leak, which contains glucose. The nurse should test the drainage for glucose to differentiate it from mucus. The client should not blow their nose, and the head of the bed should be elevated to reduce intracranial pressure.
在美國 NCLEX 中，若液體帶血，葡萄糖測試會因血液本身含糖而不準確，此時應考「Halo sign」（液體滴在紗布上形成中心紅、外圈淡黃的光環）。台灣臨床同樣重視此評估，但考試時需注意題幹描述液體是否「澄清」。