— 照護管理 · HARD · SATA —
護理師照護一位疑似中風的病人，為預防進一步併發症，應優先採取哪些措施？（選所有適合的）
A nurse is caring for a client with a suspected stroke. Which of the following should the nurse prioritize to prevent further complications? (Select all that apply.)
- AKeep the client NPO until a swallow assessment is performed✓ 正解在進行吞嚥評估前，讓病人禁食（NPO）
- BElevate the head of the bed to 30 degrees✓ 正解將床頭抬高30度
- CPerform passive range of motion exercises every 4 hours每4小時執行被動關節活動運動
- DAdminister aspirin 325 mg immediately if conscious若病人意識清醒，立即給予325 mg阿斯匹靈
- EMonitor and maintain blood pressure within target ranges✓ 正解監測並維持血壓在目標範圍內
— Explanation · 中文詳解 —
中風病人最常見的併發症為誤吸與腦水腫。NPO 可預防誤吸直到吞嚥功能確認，床頭抬高 30 度有助於減少顱內壓。監測血壓是為了保護腦灌流壓（CPP）並預防出血或灌流不足。D 選項錯誤，未經影像確認是出血性還是缺血性中風前，絕對不可隨意服用阿斯匹靈。
Priorities for a suspected stroke client include keeping the patient NPO to prevent aspiration until swallowing is assessed, elevating the head of the bed to 30 degrees to reduce intracranial pressure, and monitoring blood pressure to maintain cerebral perfusion. Aspirin should not be administered until imaging confirms the stroke is ischemic rather than hemorrhagic.
✦ 台美臨床差異
美國有明確的 Stroke Code 流程；台灣急診亦有類似處理流程，但執行細節可能依醫院標準有所差異。