— 照護管理 · HARD · MCQ —
急診室中有數位病人主訴腹痛，護理師應優先評估哪一位？
A client in the emergency department reports abdominal pain. Which client should the nurse assess first?
- AA 25-year-old with RLQ pain and a temperature of 101.2°F一位 25 歲右下腹痛且體溫 101.2°F 的病人
- BA 45-year-old with history of constipation complaining of bloating一位有便秘病史並抱怨脹氣的 45 歲病人
- CA 55-year-old with sudden onset of severe epigastric pain radiating to the back✓ 正解一位突然出現嚴重上腹痛並輻射至背部的 55 歲病人
- DA 30-year-old with cramping and diarrhea for 2 days一位腹絞痛並腹瀉兩天的 30 歲病人
— Explanation · 中文詳解 —
此題考驗急診分流（Triage）。C 選項描述的症狀高度懷疑為腹主動脈瘤破裂或急性胰臟炎，屬於威脅生命的緊急狀況。A 選項疑似闌尾炎，雖需手術但通常生命徵象較穩定；D、B 為常見消化道問題，不屬於急診高危險群。
This question tests emergency triage principles, prioritizing life-threatening conditions. Sudden severe epigastric pain radiating to the back suggests a vascular emergency like a ruptured abdominal aortic aneurysm or acute pancreatitis, which requires immediate assessment over stable appendicitis or common gastrointestinal issues.
✦ 台美臨床差異
美國急診分流（Triage）非常嚴謹，護理師分流權限高；台灣急診分流則由護理師評估後，常會與醫師即時討論。