— 生理適應 · EASY · MCQ —
護理師照顧左手臂剛打石膏的病人，下列哪項發現需立即通知醫師？
A nurse is caring for a client with a new cast on the left arm. Which assessment finding requires immediate notification to the healthcare provider?
- AEdema of the fingers手指水腫
- BSkin warmth near the cast edges石膏邊緣附近的皮膚溫熱
- CCapillary refill of 2 seconds毛細血管再充盈時間為2秒
- DAbsence of a radial pulse✓ 正解橈動脈搏動消失
— Explanation · 中文詳解 —
石膏（Cast）若過緊會限制血液循環，導致腔室症候群（Compartment Syndrome）。評估末梢神經血管狀況（Neurovascular Assessment）是護理師的絕對責任。脈搏消失（Absence of radial pulse）顯示末梢循環已中斷，這屬於血管受損的緊急徵兆，若不及時處理將導致肢體缺血性壞死（Ischemic Necrosis）。其他症狀如水腫或皮膚溫暖雖需注意，但不及脈搏消失危急。
The absence of a radial pulse indicates severe neurovascular compromise, such as compartment syndrome, which can lead to ischemic necrosis if not treated immediately. While mild edema or warmth may be expected, a missing pulse is a critical emergency requiring immediate provider notification.