— 照護管理 · HARD · MCQ —
交班時，護理師應優先照護下列哪位病人？
Which of the following clients should the nurse prioritize during the shift change?
- AA client with a scheduled dressing change for a surgical wound外科傷口需定期換藥的病人
- BA client awaiting discharge papers for home等待出院文件的病人
- CA client with a new onset of confusion and slurred speech✓ 正解新出現意識混亂及構音困難的病人
- DA client requesting pain medication for a headache因頭痛要求止痛藥的病人
— Explanation · 中文詳解 —
在 NCLEX 考試中，護理師需運用 ABC（氣道、呼吸、循環）原則及安全優先級來判定照護順序。意識改變（Confusion）合併構音困難（Slurred speech）是神經系統異常的典型徵兆，極可能為急性缺血性中風或嚴重的代謝性腦病變。這類病人處於腦組織損傷的風險中，屬於「不穩定且具生命威脅」，必須最優先評估與介入。其他選項均為穩定或常規性護理工作，不具備急性生理惡化的緊急性。
The nurse should prioritize the client with new-onset confusion and slurred speech, as these are sudden neurological changes indicative of a potential stroke or metabolic encephalopathy. This condition is unstable and life-threatening, requiring immediate assessment and intervention. Other options involve routine or non-acute tasks that do not pose an immediate threat to life.