— 降低風險 · MEDIUM · MCQ —
一位懷疑中風的病人，護理師在評估時，若發現下列哪項症狀需立即通知醫師？
A nurse is assessing a client with a suspected stroke. Which clinical manifestation should the nurse prioritize to alert the healthcare provider immediately?
- ASlurred speech構音障礙
- BSudden onset of altered level of consciousness✓ 正解突然出現意識狀態改變
- CUnilateral weakness of the arm單側手臂無力
- DAsymmetric facial droop面部不對稱下垂
— Explanation · 中文詳解 —
中風的症狀包含臉部下垂、單側肢體無力與語言障礙，但意識改變代表顱內壓力升高或大腦灌流嚴重受損，是病情惡化最顯著的指標。相較於其他神經缺損症狀，意識狀況的改變對生命徵象與預後威脅最大，需立即採取緊急介入。
A sudden alteration in the level of consciousness is the most critical finding as it indicates increased intracranial pressure or compromised brainstem function, requiring immediate emergency intervention. While other symptoms like slurred speech or weakness are indicative of stroke, changes in consciousness pose the greatest immediate threat to life.
✦ 台美臨床差異
美國護理師常使用 NIHSS 評估；台灣護理師則多依據 GCS 評分與基本神經學檢查進行回報。