— 生理適應 · MEDIUM · MCQ —
護理師照護一位甲狀腺切除術後 4 小時的患者。哪項評估發現最為關鍵且需要立即處置？
A nurse is caring for a client who is 4 hours post-thyroidectomy. Which assessment finding is the most critical and requires immediate intervention?
- ASerum calcium level of 8.8 mg/dL血清鈣濃度 8.8 mg/dL
- BLaryngeal stridor✓ 正解喉鳴音
- CPain at the incision site (4/10)切口處疼痛（4/10）
- DSore throat when speaking說話時喉嚨痛
— Explanation · 中文詳解 —
甲狀腺切除術後最嚴重的併發症是氣道阻塞。喉頭喘鳴（Laryngeal stridor）表示氣道受壓或喉神經受損，是呼吸道即將關閉的徵兆，必須立即通知醫療團隊並準備插管或氣切。A 為預期發現；C 可用藥控制；D 輕微偏低但非立即致命。
The client is exhibiting signs of extrapyramidal symptoms (EPS), specifically pseudoparkinsonism, caused by dopamine blockade from chlorpromazine. Benztropine, an anticholinergic agent, is administered to restore the balance between dopamine and acetylcholine in the basal ganglia, thereby alleviating tremors and gait disturbances.
✦ 台美臨床差異
美國 NCLEX 強調 ABC 優先與即時生命威脅判斷；台灣臨床同樣重視，但對喘鳴音的緊急通報程序通常有固定標準作業流程。