— 基本照護與舒適 · MEDIUM · MCQ —
護理師照護一位打石膏的病人。下列哪項是優先評估項目？
A nurse is caring for a client with a plaster cast. What is a priority assessment?
- AThe temperature of the room室溫
- BThe color of the skin distal to the cast✓ 正解石膏遠端皮膚的顏色
- CThe weight of the cast石膏的重量
- DThe client's favorite color病人的最愛顏色
— Explanation · 中文詳解 —
打石膏（Plaster cast）的病人在護理上，最重要的優先評估是「神經血管狀態」（Neurovascular status）。石膏若過緊，會壓迫血管與神經，導致腔室症候群（Compartment Syndrome）。護理師必須評估石膏末端的顏色、溫度、脈搏、毛細血管回流與感覺，以確保肢體血液循環與神經傳導未受阻。
Neurovascular assessment is the priority for clients with casts to detect early signs of compartment syndrome or circulatory compromise. The nurse must evaluate the distal extremity for color, temperature, pulse, capillary refill, and sensation.