— 基本照護與舒適 · MEDIUM · MCQ —
病人被診斷有尿瀦留問題，下列哪項評估發現需要護理師立即處置？
A client is diagnosed with urinary retention. Which assessment finding requires immediate nursing intervention?
- AReports of feeling full主訴感到脹滿
- BDullness on percussion over the bladder膀胱區叩診呈濁音
- CSuprapubic tenderness and distention✓ 正解恥骨上壓痛與膨隆
- DFrequent small-volume voiding頻繁排出少量尿液
— Explanation · 中文詳解 —
尿瀦留（Urinary retention）病人若膀胱過度充盈，會出現恥骨上壓痛與明顯的腹部膨隆，這代表膀胱已達極限，若不立即處置，極易引發膀胱損傷、輸尿管逆流甚至腎衰竭。其他選項如頻尿可能僅是「滿溢性尿失禁」（Overflow incontinence），雖需注意，但壓痛與腹部明顯腫脹代表更急迫的物理性壓迫風險。
Suprapubic tenderness and distention indicate acute bladder overdistension, which poses a risk for bladder damage and renal compromise if not drained immediately. While other findings like dullness or overflow incontinence suggest retention, the presence of significant pain and physical distention represents the most urgent physiological threat requiring prompt intervention.