— 照護管理 · HARD · MCQ —
護理師在內科病房照顧多位病人，下列哪位病人應優先處理？
A nurse is managing a group of clients on a medical unit. Which client should the nurse see first?
- AA client with post-operative pain of 5 out of 10一位術後疼痛評分 5/10 的病人
- BA client with diabetes who has a blood glucose of 140 mg/dL一位血糖 140 mg/dL 的糖尿病人
- CA client with a new onset of sudden confusion✓ 正解一位新發突發性意識混亂的病人
- DA client with COPD who reports mild shortness of breath一位主訴輕微呼吸困難的 COPD 病人
— Explanation · 中文詳解 —
護理優先順序的判斷需依據「ABC（氣道、呼吸、循環）」與「突發性、不穩定的狀況」。突發性意識改變（New onset of sudden confusion）是一個極具臨床意義的警訊，常暗示腦部灌流不足、低血糖、敗血症、電解質不平衡或中風，具生命威脅潛力。相較之下，血糖 140 mg/dL 屬可控範圍、輕微喘氣與術後 5 分疼痛雖需處理，但均屬於相對穩定或可預期的臨床狀況。
New-onset sudden confusion is a critical sign of potential neurological or metabolic emergencies, such as stroke, hypoglycemia, or sepsis, requiring immediate assessment. Unlike moderate postoperative pain, stable blood glucose, or mild dyspnea in COPD, this symptom indicates an unstable condition that poses an immediate threat to life.