護理師協助術後活動受限的病人第一次床緣坐起,病人自訴頭暈及視力模糊。護理師應優先採取何種行動?
A nurse is assisting a client with limited mobility to sit at the edge of the bed for the first time after surgery. The client reports sudden dizziness and blurred vision. Which action is the priority?
- ACall for assistance from another staff member尋求其他工作人員協助
- BCheck the client's blood pressure測量個案的血壓
- CAssist the client to lie back down immediately✓ 正解立即協助個案躺下
- DEncourage the client to take deep breaths鼓勵個案深呼吸
術後病人第一次嘗試下床或坐起時,極易出現姿勢性低血壓(Orthostatic hypotension)。當病人自訴頭暈(Dizziness)或視力模糊(Blurred vision)時,這代表腦部灌流不足。護理師的第一優先行動應是確保病人安全,立即將病人平臥(Lie back down),以利用重力作用促進血液回流至腦部,緩解灌流不足造成的症狀,防止病人跌倒造成二次傷害。
Sudden dizziness and blurred vision upon sitting up indicate orthostatic hypotension and cerebral hypoperfusion, which pose an immediate fall risk. The priority nursing action is to assist the client back to a supine position to restore blood flow to the brain and ensure safety. Assessing vital signs or calling for help should occur only after the client is safely positioned to prevent injury.