— 照護管理 · MEDIUM · MCQ —
護理師照顧一位老年病人，下列哪項評估發現應優先回報？
A nurse is caring for an elderly patient. Which assessment finding is a priority to report?
- APresence of wrinkles出現皺紋
- BSlowed gait speed步速減慢
- CSudden onset of confusion✓ 正解突發性意識混亂
- DPresence of dry skin皮膚乾燥
— Explanation · 中文詳解 —
老年病人的突發性混亂（Sudden confusion/delirium）常是潛在重大生理病變的臨床表徵。護理師必須具備警覺性，因為老年人對感染、缺氧、電解質失衡或藥物交互作用的反應往往不典型，常以譫妄（Delirium）表現。這屬於「改變狀況」（Change in condition），必須立即回報醫師進行評估，以免延誤治療時機。
Sudden onset of confusion in an elderly patient is a priority finding as it often indicates an acute medical emergency such as infection, hypoxia, or electrolyte imbalance. Unlike expected age-related changes like wrinkles, slowed gait, or dry skin, delirium represents a significant change in condition that requires immediate medical evaluation.