— 基本照護與舒適 · HARD · MCQ —
在一位意識不清的病人身上，哪項是「急性疼痛」的徵象？
Which of the following is a sign of acute pain in an unconscious client?
- ADeep, regular breathing深層且規律的呼吸
- BFacial grimacing✓ 正解面部扭曲
- CRelaxed body posture放鬆的身體姿勢
- DDecreased heart rate心率下降
— Explanation · 中文詳解 —
對於意識不清的病人，疼痛評估需仰賴行為指標（Behavioral indicators）與生理反應。急性疼痛會啟動交感神經系統，導致心跳加快、呼吸頻率增加、血壓上升。面部扭曲（Grimacing）是疼痛刺激下常見的非自主性肌肉反應。護理師若發現病人出現這些反應，應進一步評估是否有誘發疼痛的因素，如管路牽拉或壓瘡。
In unconscious clients, acute pain is indicated by behavioral signs such as facial grimacing and physiological responses like tachycardia and increased respiratory rate. Relaxed posture and deep, regular breathing are not associated with acute pain.