— 照護管理 · HARD · SATA —
病人出現中風症狀，護理照護重點應包含哪些？（選所有適合的）
A client presents with symptoms of a stroke. Which of the following should be included in the nursing management? (Select all that apply.)
- AElevate the head of the bed to 30 degrees✓ 正解將床頭抬高 30 度
- BPerform a swallow screen before offering oral fluids✓ 正解提供口服流質前進行吞嚥篩檢
- CMaintain a strict NPO status until a speech therapist evaluation✓ 正解在語言治療師評估前維持嚴格禁食 (NPO)
- DPerform passive range-of-motion exercises every 4 hours✓ 正解每 4 小時進行被動關節活動度運動
- EAdminister aspirin immediately without a provider order未經醫師指示立即給予阿斯匹靈
— Explanation · 中文詳解 —
中風病人照護關鍵在於防止吸入與併發症。床頭抬高 30 度可降低腦壓；吞嚥評估是預防吸入性肺炎的黃金標準；肢體被動運動可預防關節攣縮與深部靜脈栓塞。未經診斷自行用藥（E）極為危險，因為需先排除出血性中風。
Nursing management for stroke includes elevating the head of the bed to reduce intracranial pressure and performing a swallow screen to prevent aspiration. Maintaining NPO status until evaluated and performing passive range-of-motion exercises help protect the airway and prevent complications like contractures.
✦ 台美臨床差異
美台皆採用 Stroke Alert 流程。台灣護理師在吞嚥篩檢的執行權責上，常配合語言治療師的標準化工具進行。