— 基本照護與舒適 · MEDIUM · MCQ —
護理師進行疼痛評估。下列哪項敘述是獲得準確疼痛分數的最佳方法？
A nurse is conducting a pain assessment. Which statement describes the best approach to obtaining an accurate pain rating?
- AAccept the client's report of pain as the primary indicator✓ 正解接受病人對疼痛的主觀報告作為主要指標
- BObserve physical signs like tachycardia to determine severity觀察心跳過速等生理徵象以判斷嚴重程度
- CCompare the client's pain to previous clients with the same diagnosis將病人的疼痛與具有相同診斷的其他病人進行比較
- DAssess the client while they are sleeping在病人睡眠時評估疼痛
— Explanation · 中文詳解 —
疼痛是主觀感受，「病人說痛就是痛」。即使生理徵象穩定或病人正在休息，也不能否定其疼痛主訴。生理徵象（如心跳加快）可能源於焦慮或其他因素，並非疼痛的特異性指標。疼痛評估應基於病人的自我報告，而非護理師的刻板印象或觀察。
Self-report is the gold standard for pain assessment, as pain is a subjective experience and the client's statement is the most reliable indicator of its presence and intensity. Physiological signs such as tachycardia are non-specific and may result from anxiety or other factors rather than pain alone.
✦ 台美臨床差異
美國疼痛評估強調「疼痛是第五個生命徵象」，台灣臨床對於疼痛評估的落實度與紀錄習慣則視醫院評鑑標準而異。