— 照護管理 · HARD · MCQ —
護理師在急診進行檢傷分類。哪位病人需要立即評估？
A nurse is triaging clients in the emergency department. Which client requires immediate assessment?
- AA client reporting persistent nausea and diarrhea for 2 days一位主訴持續噁心和腹瀉兩天的病人
- BA client with a superficial laceration on the forearm requiring sutures一位前臂有淺層裂傷需要縫合的病人
- CA client with sudden onset of unilateral weakness and slurred speech✓ 正解一位突然出現單側無力及語音含糊的病人
- DA client with a closed ankle fracture reporting 8/10 pain一位閉合性踝關節骨折並報告疼痛指數 8/10 的病人
— Explanation · 中文詳解 —
檢傷分類遵循 ABCDE 原則（Airway, Breathing, Circulation, Disability, Exposure），優先處理危及生命或肢體功能的狀況。突然出現的單側無力與構音障礙是急性缺血性中風的典型表現，具備「時間就是大腦」的緊迫性，必須立即啟動中風治療流程以爭取溶栓黃金期。
Following ABCDE triage principles, the nurse must prioritize clients with conditions threatening life or limb function. Sudden unilateral weakness and slurred speech indicate an acute ischemic stroke, where time-sensitive intervention is critical to preserve brain tissue and initiate thrombolytic therapy.