一位護理師照護車禍後多處創傷的病人，下列哪位病人應優先處理？
A nurse is caring for a client with multiple injuries after a motor vehicle accident. The nurse must prioritize which client first?
- AA client with a small laceration on the forehead bleeding minimally額頭有小割傷且出血量少的病人。
- BA client with an open fracture complaining of severe pain開放性骨折並抱怨劇烈疼痛的病人。
- CA client with a head injury who is confused and disoriented頭部受傷且意識混亂、定向力障礙的病人。
- DA client with suspected tension pneumothorax and absent breath sounds✓ 正解疑似張力性氣胸且呼吸音消失的病人。
護理優先順序應遵循 ABC（呼吸、呼吸道、循環）原則。張力性氣胸會導致縱隔移位並壓迫大血管，造成致命性的心輸出量降低，需立即進行減壓處理。骨折（B）雖疼痛，但非致命；意識改變（C）需密切監測，但氣胸的缺氧威脅更急迫；小傷口（A）屬於次要問題。
Prioritization follows the ABC (Airway, Breathing, Circulation) framework, making the client with suspected tension pneumothorax the highest priority. This condition causes mediastinal shift and compression of major vessels, leading to compromised cardiac output and severe hypoxia that requires immediate decompression. While other injuries like fractures or confusion are serious, they do not pose the same immediate threat to life as respiratory and hemodynamic collapse.
台灣急診分級制度（Triage）與美國類似，均強調整體狀況評估與生命徵象穩定度。