— 生理適應 · HARD · MCQ —
護理師在病人接受甲狀腺切除術後 4 小時進行評估，病人表示手指與口周圍有刺痛感。下列何者為優先護理措施？
A nurse is assessing a client 4 hours after a thyroidectomy. The client reports tingling in the fingers and circumoral area. What is the priority nursing intervention?
- AReview the latest hemoglobin result檢視最新血紅素結果
- BCheck for Trousseau's sign✓ 正解檢查 Trousseau 徵象
- CAdminister pain medication給予止痛藥物
- DAssess for respiratory stridor評估是否有呼吸哮鳴音
— Explanation · 中文詳解 —
甲狀腺切除術後若出現手指或口周刺痛（指端麻木），高度懷疑因誤傷副甲狀腺導致低血鈣。優先執行 Trousseau's sign 檢查以確認是否存在潛在的抽搐現象（Tetany），若確認低血鈣則需儘速補充鈣劑，避免喉部痙攣。
Tingling in the fingers and around the mouth suggests hypocalcemia, a common complication after thyroidectomy due to potential parathyroid gland damage. Checking for Trousseau's sign is the priority intervention to confirm latent tetany, allowing for prompt calcium replacement to prevent life-threatening laryngeal spasm.
✦ 台美臨床差異
美方護理師常執行手部抽搐評估檢查，台灣臨床護理師亦會執行，但對於發現異常後的 Calcium Gluconate 給藥時程常需醫師口頭醫囑或特定 Protocol。