— 照護管理 · HARD · MCQ —
對於一位突發意識狀態改變的病人，護理師應優先執行下列哪項處置？
Which of the following interventions should the nurse prioritize for a client who is experiencing a sudden change in mental status?
- AObtain a complete set of vital signs取得完整生命徵象
- BNotify the healthcare provider immediately立即通知醫療提供者
- CAssess for reversible causes such as hypoglycemia✓ 正解評估可逆轉的原因，如低血糖
- DReview the client's medication administration record檢視客戶的用藥紀錄
— Explanation · 中文詳解 —
處理意識改變時，護理評估應優先排除「可逆性」且立即致命的因素。低血糖是造成意識改變最常見且迅速可透過床邊檢測確認並處理的緊急情況。A 雖然重要，但在排除低血糖前，應確保病人的生理數據能引導診斷。D 需在收集必要資訊後進行，而非第一動作。
The nurse must prioritize assessing for reversible causes of altered mental status, such as hypoglycemia, which can be rapidly corrected at the bedside. While obtaining vital signs and reviewing medications are important, identifying and treating immediate life-threatening physiological deficits takes precedence before notifying the provider.
✦ 台美臨床差異
台美皆強調排除低血糖，唯美國護理師依 protocol 給予 D50W 較為普遍。