— 照護管理 · HARD · MCQ —
護理師進行入院評估，哪項發現需要立即向醫師報告？
A nurse is conducting an admission assessment. Which finding requires immediate reporting to the healthcare provider?
- AReports of mild pain at the incision site主訴切口處輕微疼痛
- BBlood pressure of 135/85 mmHg血壓 135/85 mmHg
- CA new onset of confusion and slurred speech✓ 正解新發意識混亂及語無倫次
- DHistory of allergic reaction to penicillin青黴素過敏史
— Explanation · 中文詳解 —
在入院評估中，護理師需優先辨識危及生命的急性狀況。新發生的意識混亂（Confusion）與言語不清（Slurred speech）是神經系統急性缺氧、腦血管意外（Stroke）或代謝異常的危險信號，屬於需要立即醫療介入的緊急狀況。其他選項如高血壓、疼痛或過敏史均屬需紀錄並後續評估的內容，但優先度低於急性神經缺損。
New-onset confusion and slurred speech are critical neurological changes that may indicate a stroke, acute hypoxia, or other life-threatening conditions requiring immediate medical intervention. While mild pain, elevated blood pressure, and known allergies are important, they do not pose the same urgent risk as acute neurological deficits.