— 生理適應 · HARD · MCQ —
頭部外傷病人鼻孔流出清澈液體，護理師應採取何種措施？
A client with a head injury displays clear fluid draining from the nose. Which action should the nurse take?
- AAsk the client to blow their nose請客戶摳鼻子
- BInsert a nasal tampon to stop the drainage插入鼻用紗布以停止引流
- CTest the fluid for glucose✓ 正解測試液體中的葡萄糖含量
- DPerform a neurological exam進行神經學檢查
— Explanation · 中文詳解 —
頭部外傷後鼻腔流出液體需懷疑腦脊髓液（CSF）外漏。測試葡萄糖含量是臨床快速評估方法（CSF 含葡萄糖，鼻黏液通常不含或極低）。禁止填塞或要求擤鼻涕，因會增加顱內壓力並導致感染風險上升。神經學檢查重要，但鑑別液體來源是當務之急。
Testing the fluid for glucose helps distinguish cerebrospinal fluid from nasal mucus, as CSF typically contains glucose. Blowing the nose or inserting nasal tampons is contraindicated because these actions increase intracranial pressure and the risk of infection. While a neurological exam is important, confirming the nature of the drainage is the immediate diagnostic priority.
✦ 台美臨床差異
美國針對腦脊髓液漏的護理規範非常嚴格，強調絕對不可嘗試止漏，台灣臨床對此也極為謹慎。