— 照護管理 · HARD · MCQ —
交班時，護理師應優先評估下列哪位病人？
Which of the following clients should the nurse assess first when receiving the shift report?
- AA client with a Foley catheter who has had 200 mL of urine output in 4 hours插有福萊氏導尿管且 4 小時內尿量為 200 mL 的病患
- BA client with a 1-day postoperative appendectomy requesting pain medication開腹闌尾切除術後第 1 天並要求止痛藥的病患
- CA client with type 2 diabetes and a fasting blood glucose of 140 mg/dL第二型糖尿病且空腹血糖為 140 mg/dL 的病患
- DA client with a new onset of sudden confusion and unequal pupils✓ 正解新發突發意識混亂且瞳孔大小不一的病患
— Explanation · 中文詳解 —
依據 ABC（呼吸、循環、神經）原則，優先評估可能有急性神經功能惡化的病人。意識混亂合併瞳孔不等大，高度懷疑腦部壓力增加或中風，需立即進行神經學評估。其他選項雖需處理，但皆屬可預期狀況或非致命性急症。
A client presenting with sudden confusion and unequal pupils requires immediate assessment as these signs suggest a neurological emergency such as increased intracranial pressure or stroke. According to ABC principles, acute neurological changes take precedence over stable conditions like expected postoperative pain, controlled hyperglycemia, or adequate urine output.
✦ 台美臨床差異
台灣醫院對此類神經急症通常會立即啟動 Stroke Code 或通知神經外科，護理師的角色為第一時間通知並準備儀器。