— 基本照護與舒適 · EASY · MCQ —
一位病人表示疼痛嚴重，下列哪項評估發現需要護理師立即介入？
A nurse is caring for a client who reports severe pain. Which assessment finding requires immediate nursing intervention?
- AA pain score of 8/10疼痛評分8/10
- BA change in mental status and confusion✓ 正解精神狀態改變和混亂
- CThe client is sleeping despite the reported pain儘管報告疼痛，病人仍在睡覺
- DAn increase in blood pressure and heart rate血壓和心率增加
— Explanation · 中文詳解 —
疼痛是主觀感受，但意識狀態改變（confusion）往往暗示著疼痛背後的潛在危機，如敗血症、顱內出血或缺氧，這是優先處理的指標。疼痛程度評分高需止痛，生理數據變化可由疼痛引起，嗜睡則可能因止痛藥副作用，但意識混亂最具急迫性。
A change in mental status and confusion is the most critical finding as it may indicate a life-threatening complication such as hypoxia, sepsis, or increased intracranial pressure. While high pain scores and elevated vital signs are expected physiological responses to pain, altered consciousness signals a potential neurological or metabolic emergency requiring immediate assessment.
✦ 台美臨床差異
美方護理評估非常重視疼痛與其他變數的關聯；台灣臨床若病人表示不痛，常忽略對其意識水平的監測。