— 照護管理 · MEDIUM · MCQ —
護理師正在督導一名新進護理師照顧四位病人。護理師應建議新進護理師優先查看哪位病人？
A nurse is supervising a newly licensed nurse who is caring for four clients. Which client should the nurse advise the newly licensed nurse to see first?
- AA client with an intravenous infusion that has infiltrated一位靜脈輸液發生滲漏的病人
- BA client with diabetes scheduled for a dressing change on a foot ulcer一位糖尿病足潰瘍預定換藥的病人
- CA client with a new onset of sudden confusion and restlessness✓ 正解一位新發突發意識混亂和煩躁不安的病人
- DA client with asthma who just returned from a nebulizer treatment一位剛接受霧化治療返回的病人性喘病人
— Explanation · 中文詳解 —
護理優先級應建立在評估急性生理變化的基礎上。意識狀態突然改變（Confusion and restlessness）是腦部灌流不足、低血糖、缺氧或敗血症的警訊，這些狀況若未處理，可能迅速發展為生命危險。相較於傷口換藥、治療後常規評估或靜脈滲漏，神經精神狀態的急性改變需要護理師最優先進行評估，以決定是否啟動緊急醫療應對。
A sudden change in mental status, such as confusion and restlessness, is a critical indicator of potential physiological emergencies like hypoxia, hypoglycemia, or sepsis. This acute neurological change requires immediate assessment to prevent rapid deterioration into life-threatening conditions. Other issues like IV infiltration or routine wound care are less urgent compared to the risk of compromised cerebral perfusion.