— 照護管理 · HARD · MCQ —
護理師正在照護一名剛入住神經內科的急性中風病人。下列哪項護理措施應優先執行以預防併發症？
A nurse is managing a client with an acute stroke who has been admitted to the neurological unit. Which action should the nurse prioritize to prevent complications?
- ATeach the family how to perform passive exercises教導家屬如何執行被動運動
- BPerform passive range-of-motion exercises every 4 hours每 4 小時執行被動關節活動度運動
- CAdminister prophylactic subcutaneous heparin給予皮下注射預防性肝素
- DAssess swallowing ability before allowing oral intake✓ 正解允許經口進食前評估吞嚥能力
— Explanation · 中文詳解 —
急性中風病患最危險的早期併發症是吸入性肺炎。在確認嚥下功能（Swallowing assessment）前嚴禁給予任何口服藥物或食物，此為護理安全之首要。其他運動與抗凝血治療均為後續預防長期併發症的步驟。
Aspiration pneumonia is the most dangerous early complication in acute stroke patients, making airway safety the top priority. The nurse must assess swallowing ability before allowing any oral intake to prevent aspiration. Other interventions, such as passive exercises and DVT prophylaxis, are important but secondary to ensuring the airway is protected.
✦ 台美臨床差異
美國神經內科常有專責 Speech Language Pathologist (SLP) 評估吞嚥，台灣則常由護理師執行初步篩檢。