— 照護管理 · MEDIUM · MCQ —
護理師照顧疑似中風的病人，首要考量是什麼？
A nurse is caring for a client with a suspected stroke. What is the priority concern?
- AThe client's emotional state病人的情緒狀態
- BThe client's ability to speak病人的言語能力
- CThe client's airway patency and neurological status✓ 正解病人的呼吸道通暢性及神經狀態
- DThe client's nutrition status病人的營養狀況
— Explanation · 中文詳解 —
中風病人可能伴隨吞嚥障礙或意識喪失，因此呼吸道通暢（Airway patency）是首要考量，其次是監測神經學指標（Neuro status）以評估中風演變或惡化。營養、情緒等均需處理，但均需在維持生理穩定（ABC 原則）之後。
Airway patency and neurological status are the priority concerns because stroke patients may experience dysphagia or decreased consciousness, risking aspiration and respiratory compromise. Following the ABCs of emergency care, maintaining a patent airway takes precedence over addressing speech deficits, nutritional needs, or emotional distress.
✦ 台美臨床差異
美國有完善的 Stroke Code 系統；台灣各大醫院亦推行腦中風取栓團隊（Thrombectomy team），兩者皆高度重視神經學監測。