— 降低風險 · MEDIUM · MCQ —
護理師評估一位右下肢剛打上石膏的病人，哪項發現應立即報告醫師？
A nurse is assessing a client with a newly applied plaster cast on the right lower leg. Which finding should the nurse report to the provider immediately?
- AVisible swelling at the cast edges石膏邊緣可見腫脹
- BParesthesia of the toes✓ 正解腳趾感覺異常
- CWarmth of the toes腳趾溫暖
- DCapillary refill time of 3 seconds毛細血管回充時間為 3 秒
— Explanation · 中文詳解 —
石膏邊緣的末梢循環評估（Neurovascular check）極為重要。Paresthesia（感覺異常或麻木）是神經受壓迫的早期徵兆，若不處理可能導致不可逆的神經損傷。D 選項 3 秒尚在可接受範圍，C 為正常，A 雖有腫脹但若無神經血管症狀，通常先採取抬高患肢處理。
Paresthesia is an early sign of nerve compression, which can lead to irreversible damage if not addressed immediately. While minor swelling, warmth, and a capillary refill time of 3 seconds are generally expected or normal findings, paresthesia requires urgent provider notification.
✦ 台美臨床差異
美國護理標準強調 6P 評估，台灣護理師亦熟練，但在評估頻率上台灣因病人量大常顯得較為匆忙。