— 生理適應 · MEDIUM · SATA —
護理師照顧甲狀腺切除術後病人，哪些評估項目對偵測併發症至關重要？（選所有適合的）
A nurse is caring for a client following a thyroidectomy. Which assessments are critical to detect complications? (Select all that apply.)
- AMonitor for laryngeal stridor✓ 正解監測是否有喉頭喘鳴
- BAssess for Trousseau's sign✓ 正解評估 Trousseau 氏徵象
- CCheck the back of the neck for blood pooling✓ 正解檢查頸後是否有血液積聚
- DAssess the ability to speak clearly✓ 正解評估說話是否清晰
- EMonitor for signs of hemorrhage✓ 正解監測出血徵象
— Explanation · 中文詳解 —
甲狀腺切除術後（Post-thyroidectomy）的護理重點在於監測致命併發症，包括氣道阻塞（喉頭水腫或出血壓迫）與低血鈣症。術後頸部腫脹與出血可能壓迫氣管，導致呼吸困難；而副甲狀腺若在手術中受損或被移除，會導致血鈣迅速下降，引發手足抽搐、喉頭痙攣等危險狀況。評估這些徵兆是護理師在術後 24-48 小時內的首要責任。
Critical post-thyroidectomy assessments include monitoring for airway obstruction, indicated by laryngeal stridor or hoarseness suggesting laryngeal nerve damage. Nurses must also check for hemorrhage, particularly by inspecting the back of the neck where blood may pool due to gravity. Furthermore, assessing for Trousseau's sign helps detect hypocalcemia resulting from potential parathyroid gland injury, which can lead to life-threatening tetany.