— 生理適應 · HARD · MCQ —
一位疑似腦膜炎的病人預計進行腰椎穿刺，護理師的優先處置為何？
A patient with suspected meningitis is scheduled for a lumbar puncture. Which nursing action is priority?
- AObtain informed consent from the physician取得醫師的知情同意
- BAdminister prophylactic antibiotics給予預防性抗生素
- CPosition the client in a lateral recumbent position with knees flexed將病人置於側臥屈膝姿勢
- DCheck for signs of increased intracranial pressure✓ 正解檢查是否有顱內壓增加的徵象
— Explanation · 中文詳解 —
腰椎穿刺（Lumbar Puncture）是一項高風險檢查。若病人存在顱內壓升高（Increased ICP）的跡象（如視神經乳頭水腫、意識改變、頭痛嘔吐），進行穿刺可能導致腦疝（Brain Herniation），嚴重者可致命。因此，在執行穿刺前，護理師必須優先評估並排除 ICP 升高的風險，這是確保病人安全的第一要務。
Checking for signs of increased intracranial pressure is the priority because performing a lumbar puncture on a client with elevated ICP can precipitate fatal brain herniation. While positioning and obtaining consent are important, ensuring the procedure does not cause catastrophic neurological injury takes precedence.