護理師規劃照護計畫,下列哪幾位病人應優先處理?(選所有適合的)
A nurse is planning care for a group of clients. Which of the following clients should be prioritized? (Select all that apply.)
- AA client with severe hypokalemia reporting muscle weakness✓ 正解主訴肌肉無力之嚴重低血鉀病人
- BA client with suspected myocardial infarction reporting crushing chest pain✓ 正解主訴壓榨性胸痛之疑似心肌梗塞病人
- CA client scheduled for discharge with a stable wound傷口穩定準備出院之病人
- DA client with a new onset of altered mental status✓ 正解新出現意識狀態改變之病人
- EA client with a routine dressing change order有常規傷口換藥醫囑之病人
護理師在規劃照護計畫時,必須依據病人的病情危急程度來決定優先順序。核心概念是「生命優先原則」(ABC優先原則的延伸),即優先處理威脅生命、可能導致永久性損害或需要立即介入的狀況。 正確答案 A, B, D 均代表了需要高度優先處理的病人。A(嚴重低血鉀 Hypokalemia)可能引發致命性的心律不整,必須立即處理。B(疑似心肌梗塞合併胸痛)是急性冠狀動脈症候群的表現,可能導致心肌壞死,需迅速診斷與治療。D(新出現的意識狀態改變 Altered mental status)可能表示腦部出現嚴重問題(如缺氧、出血、代謝異常、感染),需立即評估原因並介入。 選項 C(預計出院且傷口穩定)和 E(常規換藥)雖然也是護理工作的一部分,但其病情相對穩定,不涉及立即的生命危險,因此可以排在 A、B、D 之後處理。
Prioritization is based on the principle of addressing life-threatening conditions first. Severe hypokalemia (Option A) risks lethal dysrhythmias, suspected myocardial infarction (Option B) requires immediate cardiac intervention, and new-onset altered mental status (Option D) suggests serious neurological or metabolic issues. Stable discharge clients (Option C) and those needing routine care (Option E) are lower priority.