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照護管理 · HARD · MCQ

一位急診檢傷護理師正在評估在極度繁忙的下午湧入的大量病患。哪位病患強烈地要求護理師必須啟動「最高精準立即優先處理 (Highest priority)」級別的檢傷分類?

An ER triage nurse evaluates an influx of critically unstable clients arriving heavily simultaneously during an extremely busy afternoon explicitly. Which profoundly dangerous client strongly uniquely reliably requires the nurse to powerfully rapidly rigorously firmly initiate the highest level of precise immediate emergency triage prioritization securely gracefully flawlessly?

  • AA 24-year-old male asthmatic whose breath sounds have entirely precipitously vanished causing profound silent chest syndrome.✓ 正解
    一位 24 歲男性氣喘患者,其呼吸音已完全急遽消失,導致嚴重的無聲胸徵候群。
  • BA client clutching their right upper abdomen and reporting sharp, severe pain upon continuous deep palpation.
    一位緊抓右上腹部並報告在持續深觸診時有尖銳劇痛的病人。
  • CA client accurately presenting with chronic exacerbation of heart failure still heavily requiring continuous intravenous furosemide diuretic therapy.
    一位準確呈現慢性心臟衰竭惡化,但仍高度需要持續靜脈注射呋塞米利尿劑治療的病人。
  • DA violently shivering client diagnosed with profound systemic septic shock and plummeting blood pressure.
    一位被診斷為嚴重全身性敗血性休克且血壓急遽下降的劇烈顫抖病人。
Explanation · 中文詳解

本題再次強化呼吸道檢傷 (Triage classification)。Airway 永遠大於 Circulation。選項 A 的病患出現「Silent Chest Syndrome (沉默的胸腔)」。氣喘從喘鳴音 (wheezing) 變成完全沒聲音,代表支氣管 100% 痙攣塞住,空氣完全進不去了。如果不秒給 Epi 並插管,大約這幾分鐘內心跳就會停掉。他是 Airway (C) 等級的死神。選項 D 敗血性休克是 Circulation (A) 等級的死神,順位排在 Airway 後。

The client with asthma presenting a silent chest is in immediate life-threatening danger due to complete airway obstruction, requiring urgent airway management. In triage, airway compromise takes precedence over circulation issues, making this the highest priority for rapid intervention.

✦ 台美臨床差異

急診檢傷只要看見 Airway 封閉的徵兆,直接選他。

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