護理師照顧四位病人，應優先評估哪一位？
A nurse is caring for four clients. Which client should the nurse assess first?
- AA client with pneumonia who has an oxygen saturation of 91% on 2 L/min患有肺炎且氧飽和度為 91%（於 2 L/min 下）的病人
- BA client with a head injury who has become increasingly restless and agitated✓ 正解患有頭部外傷且變得越來越煩躁不安的病人
- CA client who had a cholecystectomy 4 hours ago and reports 6/10 pain4 小時前接受膽囊切除術並報告疼痛指數為 6/10 的病人
- DA client with chronic kidney disease whose creatinine is 3.5 mg/dL患有慢性腎臟病且肌酸酐為 3.5 mg/dL 的病人
優先順序應遵循 ABC（呼吸、循環）或神經系統的變化。頭部外傷病人變得焦躁不安（Restless/Agitated）通常是顱內壓增高（IICP）或缺氧的早期徵兆，屬於醫療緊急狀況。A（肺炎 SpO2 91%）雖需關注但相對穩定；B（CKD 肌酸酐高）是預期表現；D（術後疼痛）非立即生命威脅。
The nurse should assess the client with a head injury first because restlessness and agitation are early signs of increased intracranial pressure or hypoxia, which are medical emergencies. While the client with pneumonia has low oxygen saturation, it is expected and less urgent than potential neurological deterioration. Post-operative pain and elevated creatinine in chronic kidney disease are expected findings that do not require immediate intervention over airway and neurological threats.
美國 NCLEX 非常強調「意識改變」作為優先判斷指標；台灣臨床上疼痛控制常被列為首要抱怨，需注意區分生命徵象與主觀需求。