— 照護管理 · HARD · MCQ —
護理師在急診室進行檢傷分類，哪位病人需要最立即的評估？
A nurse is triaging clients in the emergency department. Which client requires the most immediate assessment?
- AA client with a fever of 101°F and cough發燒101°F且咳嗽的病人
- BA client with a sudden onset of chest pain and diaphoresis✓ 正解突然發作胸痛併盜汗的病人
- CA client with a small laceration on the forearm前臂有小割傷的病人
- DA client with a complaint of lower back pain for one week主訴下背痛一週的病人
— Explanation · 中文詳解 —
急診檢傷分類（Triage）的優先級判斷遵循 ABC 原則（Airway, Breathing, Circulation）。胸痛伴隨冒冷汗是心肌梗塞（Myocardial Infarction）的典型表現，這意味著心肌正處於缺氧壞死過程，屬於 Circulation 類別的緊急狀況，若不立即處理將導致心律不整甚至猝死。
Chest pain with diaphoresis indicates potential myocardial infarction, a circulation emergency requiring immediate assessment. This presentation takes priority over stable fevers, minor wounds, or chronic pain under triage protocols.