— 照護管理 · HARD · MCQ —
護理師照護一位術後病人，發現其突然意識混亂且躁動。優先採取的護理行動為何？
A nurse is caring for a client who suddenly becomes confused and restless after a routine surgery. What is the nurse's priority action?
- AAssess the client's vital signs and oxygen saturation✓ 正解評估病人的生命徵象和血氧飽和度
- BRestrain the client to prevent injury約束病人以防止受傷
- CNotify the family about the change in mental status通知家屬關於精神狀態的變化
- DAdminister the PRN sedative medication ordered for agitation給予醫師指示備用劑量的鎮靜藥物以處理躁動
— Explanation · 中文詳解 —
突發意識改變在術後病人中通常由缺氧、低血壓、低血糖或電解質失衡引起。護理優先順序為「評估（Assessment）」，而非介入。在未釐清病因前，給予鎮靜劑（D）可能掩蓋病情惡化或加重呼吸抑制；約束（B）可能增加病人焦慮與風險；通知家屬（C）應在穩定病人並取得初步數據後進行。
Postoperative confusion and restlessness often indicate physiological instability such as hypoxia, hypotension, or electrolyte imbalance. The nurse's priority is to assess vital signs and oxygen saturation to identify the underlying cause before intervening. Administering sedatives or applying restraints without assessment may mask symptoms or worsen respiratory depression.
✦ 台美臨床差異
台美均強調 ABC 優先原則，但在評估工具使用上，台灣護理師較常使用 GCS 進行紀錄。