— 降低風險 · MEDIUM · MCQ —
護理師評估甲狀腺切除術後 2 小時的病人，病人出現手指麻木與口周感覺異常。護理師應優先採取哪項行動？
A nurse is assessing a client who is 2 hours post-thyroidectomy. The client exhibits tingling of the fingers and perioral numbness. Which action should the nurse take first?
- AAssess for Trousseau's sign✓ 正解評估圖塞勞氏徵象 (Trousseau's sign)
- BMonitor oxygen saturation levels監測氧氣飽和度
- CAdminister the prescribed pain medication給予處方止痛藥
- DCheck the surgical incision for bleeding檢查手術切口是否有出血
— Explanation · 中文詳解 —
甲狀腺切除術後，若手術過程中不慎誤傷或切除副甲狀腺，會導致副甲狀腺素（PTH）分泌不足，引發急性低血鈣（Hypocalcemia）。低血鈣會導致神經肌肉興奮性異常，出現手指麻木、口周感覺異常，嚴重時甚至引發喉頭痙攣（Laryngeal stridor），危及呼吸道安全。Trousseau 氏徵象（透過綁血壓計誘發手部痙攣）是檢測隱性低血鈣的敏感指標，需優先評估以利及時治療。
Tingling and perioral numbness are early signs of hypocalcemia, a common complication after thyroidectomy due to potential damage to the parathyroid glands. The nurse should first assess for Trousseau's sign to confirm latent tetany and then notify the provider for calcium replacement.