— 生理適應 · HARD · MCQ —
一位大腿骨折的患者突然變得躁動與混亂。護理師注意到患者胸部與頸部出現出血點（petechiae）。護理師的優先處置為何？
A client with a long-bone fracture of the femur becomes suddenly restless and confused. The nurse notes petechiae on the client's chest and neck. What is the nurse's priority action?
- AApply a cold compress to the fracture site在骨折部位敷冰
- BPerform a neurological assessment (GCS)進行神經學評估（GCS）
- CAdminister an anti-anxiety medication給予抗焦慮藥物
- DElevate the head of the bed and provide oxygen✓ 正解抬高床頭並提供氧氣
— Explanation · 中文詳解 —
長骨骨折後出現躁動、意識混亂及典型出血點（胸頸部），高度懷疑為脂肪栓塞症候群（Fat Embolism Syndrome）。脂肪顆粒進入肺循環會導致急性缺氧，故首要措施是提升床頭以改善通氣並給予氧氣支持呼吸。A 無關；C 會遮蓋意識變化；B 雖重要但非穩定生命徵象的首選。
The presence of petechiae, restlessness, and confusion following a long-bone fracture suggests fat embolism syndrome, which causes respiratory distress due to fat globules obstructing pulmonary circulation. The priority nursing action is to elevate the head of the bed and administer oxygen to improve ventilation and address hypoxia.
✦ 台美臨床差異
美國 NCLEX 常考脂肪栓塞的典型徵象（出血點）；台灣臨床則對骨折後肺栓塞（PE）討論較多，脂肪栓塞考點密度略低。