— 降低風險 · MEDIUM · MCQ —
護理師照護一位剛完成甲狀腺切除術的病人，哪項評估發現是護理師需優先辨識的？
A nurse is caring for a client who has just returned from a thyroidectomy. Which assessment finding is the priority for the nurse to identify?
- ADifficulty swallowing吞嚥困難
- BHoarseness of the voice聲音嘶啞
- CStridor on inhalation✓ 正解吸氣時出現哮鳴音
- DIncisional pain切口疼痛
— Explanation · 中文詳解 —
甲狀腺術後最嚴重的併發症是氣道阻塞。吸氣性哮鳴（Stridor）代表喉頭水腫或聲帶麻痺導致的呼吸道狹窄，若不即時處理可能迅速演變為無法插管之窒息。相比之下，聲音嘶啞、吞嚥困難或傷口疼痛雖需留意，但皆不具備如氣道阻塞般的生命威脅迫切性。
Stridor upon inhalation is the priority finding as it indicates upper airway obstruction, often caused by laryngeal edema or vocal cord paralysis after thyroidectomy. This represents a medical emergency requiring immediate intervention to prevent asphyxiation, whereas hoarseness, dysphagia, and incisional pain are less critical.
✦ 台美臨床差異
美國護理師常執行快速評估並啟動緊急醫療小組（MET）；台灣護理師通常先呼叫值班醫師處理。