— 生理適應 · MEDIUM · MCQ —
一位甲狀腺切除術後病人突然出現手指與腳趾刺痛感。護理師接下來應採取什麼步驟？
A client recovering from a thyroidectomy suddenly experiences tingling in the fingers and toes. What is the nurse's next step?
- AAssess the surgical incision site for bleeding評估手術切口部位是否有出血
- BElevate the head of the bed抬高床頭
- CCheck the client's blood pressure using a cuff✓ 正解使用袖帶測量病人的血壓
- DAdminister an analgesic medication給予止痛藥物
— Explanation · 中文詳解 —
甲狀腺切除後出現末梢麻痺，應懷疑甲狀腺副腺受損導致低血鈣。Trousseau 徵象（測量血壓時誘發手足抽搐）是檢測隱性手足抽搐的標準步驟。B（止痛藥）無法解決低血鈣；B、A 與呼吸或出血相關，但刺痛感專指電解質不平衡。
Tingling after thyroidectomy suggests hypocalcemia due to parathyroid gland injury. Inflating a blood pressure cuff to check for Trousseau’s sign is a standard nursing assessment to detect latent tetany associated with low calcium levels.
✦ 台美臨床差異