— 照護管理 · EASY · MCQ —
護理師在內外科病房進行優先級評估，哪位病人應優先處理？
A nurse is prioritizing care on a medical-surgical unit. Which client should the nurse see first?
- AA client with a new onset of sudden confusion and restlessness✓ 正解一位新發作突發性意識混亂和煩躁不安的病人
- BA client with type 2 diabetes requesting a meal tray一位第二型糖尿病要求餐盤的病人
- CA client asking for a PRN pain medication for mild discomfort一位因輕微不適要求給予 PRN 止痛藥的病人
- DA client with a scheduled dressing change for a chronic wound一位慢性傷口需要定期換藥的病人
— Explanation · 中文詳解 —
護理優先級（Prioritization）遵循 ABC（Airway, Breathing, Circulation）與「致命性評估」原則。新發生的意識混亂（Confusion）與躁動（Restlessness）是神經系統或代謝異常的警訊，可能暗示缺氧、低血糖、敗血症或急性腦部病變，這些狀況隨時可能危及生命，必須優先評估與處理。
New-onset confusion and restlessness are potential signs of life-threatening conditions such as hypoxia, sepsis, or acute neurological changes. These symptoms require immediate assessment and intervention, prioritizing them over routine tasks like meals, mild pain management, or stable wound care.