— 生理適應 · HARD · MCQ —
一位剛打上手臂石膏的病人反映疼痛加劇且嗎啡無法緩解，手指有麻刺感。護理師應先做什麼？
A client with a newly applied arm cast reports increasing pain that is not relieved by morphine, and a tingling sensation in the fingers. What should the nurse do first?
- AApply ice to the cast to reduce swelling在石膏上冰敷以減輕腫脹
- BNotify the healthcare provider immediately✓ 正解立即通知醫療提供者
- CElevate the arm above the heart level將手臂抬高超過心臟水平
- DRe-evaluate the pain in 30 minutes30 分鐘後重新評估疼痛
— Explanation · 中文詳解 —
疼痛無法由止痛藥緩解（Pain out of proportion）是腔室症候群（Compartment Syndrome）的早期紅旗徵兆。這是一種外科急症，可能需要切開減壓（Fasciotomy）。護理師必須立即通知醫師（B）。抬高（C）在腔室症候群中反而可能惡化缺血。
Unrelieved pain and paresthesia are early signs of compartment syndrome, a surgical emergency caused by increased pressure within a confined space. The nurse must notify the healthcare provider immediately to prevent permanent nerve damage and muscle necrosis. Elevating the limb above heart level is contraindicated as it reduces arterial perfusion and worsens ischemia.
✦ 台美臨床差異
無差異。腔室症候群的「6 Ps」評估是全球護理公認的急症標準。