— 照護管理 · HARD · MCQ —
急診護理師進行檢傷分類，哪位病人應優先處理？
A nurse is performing triage in an emergency department. Which client should be seen first?
- AA client with a minor headache and clear nasal discharge一位有輕微頭痛和清澈鼻涕分泌物的病人
- BA client with a suspected closed ankle fracture一位疑似閉合性踝關節骨折的病人
- CA client with a superficial abrasion on the forearm一位前臂有表淺擦傷的病人
- DA client with sudden onset of severe abdominal pain✓ 正解一位突發性劇烈腹痛的病人
— Explanation · 中文詳解 —
在急診檢傷分類（Triage）中，必須依據 ABCDE 原則（呼吸、循環、神經等）優先處理潛在致命的病人。突發性劇烈腹痛（Severe abdominal pain）可能隱含腹主動脈瘤破裂、異位懷孕破裂、穿孔或腸缺血，這些狀況皆可能在短時間內導致休克或死亡，屬於高優先級（Emergent）。相比之下，擦傷、骨折或輕微頭痛皆屬相對穩定（Non-urgent/Urgent）的個案。
Triage prioritizes clients with potential life-threatening conditions based on the ABCDE approach. Sudden severe abdominal pain requires immediate assessment as it may indicate critical pathologies such as a ruptured ectopic pregnancy, bowel perforation, or aortic aneurysm.
✦ 台美臨床差異
美國急診檢傷常用 ESI（Emergency Severity Index）系統，將病人分為 5 級。劇烈腹痛通常被歸類為 ESI 2 級（High resource needed），需迅速評估。