— 生理適應 · HARD · MCQ —
一位疑似腦膜炎的病患出現突發高燒與頸部僵硬。護理師的首要行動為何？
A client with suspected meningitis develops a sudden high fever and a stiff neck. What is the nurse's priority action?
- APrepare for lumbar puncture準備腰椎穿刺
- BInitiate droplet precautions✓ 正解實施飛沫隔離措施
- CAdminister pain medication給予止痛藥物
- DPlace the client in a quiet, dark room將病人安置於安靜、黑暗的房間
— Explanation · 中文詳解 —
腦膜炎具有高度傳染性，且細菌性腦膜炎可能導致嚴重併發症。首要行動必須是預防傳染他人（採取飛沫隔離）。D 選項可以緩解光敏感與不適，C 選項緩解疼痛，A 選項為診斷措施，皆在防護隔離措施啟動後才執行。優先維護大眾安全是護理的核心原則。
Meningitis is highly contagious, and bacterial meningitis can lead to severe complications. The priority action must be to prevent transmission to others by initiating droplet precautions. While options A, C, and D address diagnosis, pain management, and environmental comfort, infection control is the primary nursing responsibility to ensure public safety.
✦ 台美臨床差異
美台對傳染病防治的隔離規範皆極為嚴格且一致。