— 照護管理 · EASY · MCQ —
護理師在急診進行檢傷分類，哪位病人需要醫護人員立即評估？
A nurse is triaging clients in the emergency department. Which client requires immediate assessment by the healthcare provider?
- AA client with a sudden onset of dyspnea and deviation of the trachea✓ 正解一位突然出現呼吸困難且氣管偏移的客戶
- BA client with a superficial laceration on the forearm requiring sutures一位前臂有淺層割傷需縫合的客戶
- CA client with localized abdominal pain and a stable blood pressure一位局部腹痛且血壓穩定的客戶
- DA client with a closed fracture of the radius reporting pain level 6/10一位橈骨閉合性骨折且疼痛程度為 6/10 的客戶
— Explanation · 中文詳解 —
氣管偏移與突發性呼吸困難是張力性氣胸的典型徵象，屬於致命性呼吸窘迫。根據 ABC 原則（氣道、呼吸、循環），處理呼吸道暢通與換氣問題為最優先。其他選項的骨折、傷口與腹痛雖需處理，但皆不具備立即性生命威脅。
Tracheal deviation combined with sudden dyspnea indicates a tension pneumothorax, which is a life-threatening respiratory emergency requiring immediate intervention. According to ABC priorities, securing airway and breathing takes precedence over other injuries. While the other clients have valid concerns, their conditions are not immediately fatal.
✦ 台美臨床差異
美台對於張力性氣胸的處置均為緊急醫療優先，台灣檢傷制度與美國 ESI 系統在處理致命性呼吸問題上高度一致。