— 基本照護與舒適 · EASY · MCQ —
護理師協助行動受限的病人移位至床邊，病人起身時感到頭暈。護理師應採取的第一優先措施為何？
A nurse is assisting a client with limited mobility to sit at the bedside. The nurse notices the client feeling dizzy and lightheaded upon standing. What is the priority nursing action?
- ACheck the client's blood pressure immediately立即測量病人的血壓
- BInstruct the client to deep breathe指示病人深呼吸
- CAssist the client to return to a supine position✓ 正解協助病人回到仰臥姿勢
- DCall for assistance to move the client to a chair尋求協助將病人移至椅子上
— Explanation · 中文詳解 —
此臨床情境為姿勢性低血壓（Orthostatic Hypotension），常見於長期臥床或體液不足的病人。當病人由臥姿變換為站姿時，血液因重力滯留於下肢，導致腦部灌流不足而出現暈眩。優先護理措施應以病人安全為首要考量，立即停止導致暈眩的活動，並協助病人回到臥姿，以減輕心臟負擔並迅速恢復腦部血液循環，預防跌倒造成二次傷害。
The client is experiencing orthostatic hypotension, characterized by dizziness due to decreased cerebral perfusion upon standing. The priority action is to ensure safety by assisting the client back to a supine position, which facilitates venous return and restores blood flow to the brain, thereby preventing falls.