— 生理適應 · MEDIUM · SATA —
一位腿部剛打上石膏的病人。哪些發現應立即報告？（選所有適合的）
A nurse is caring for a client with a new cast on their leg. Which findings should be reported? (Select all that apply.)
- AToes are pale and cool to touch✓ 正解腳趾蒼白且觸感冰冷
- BPatient reports numbness and tingling✓ 正解患者主訴麻木與刺痛感
- CInability to move the toes✓ 正解無法活動腳趾
- DMinimal itching under the cast石膏下輕微搔癢
- EPain unrelieved by medication and elevation✓ 正解疼痛經藥物與抬高患肢後仍無法緩解
— Explanation · 中文詳解 —
剛上石膏的肢體需密切監測神經血管狀態，以防範腔室症候群（Compartment syndrome）。石膏若過緊會壓迫組織，導致血液供應中斷。護理師應使用「5P」原則評估：疼痛（Pain）、蒼白（Pallor）、脈搏消失（Pulselessness）、感覺異常（Paresthesia）與癱瘓（Paralysis）。
Pale, cool toes indicate impaired arterial perfusion, while numbness, tingling, and inability to move toes suggest nerve compression or motor deficits. These findings, along with pain unrelieved by medication, are critical indicators of potential compartment syndrome or neurovascular compromise that require immediate reporting.