— 生理適應 · HARD · SATA —
護理師照護甲狀腺切除術後病人，哪些評估發現需立即回報醫師？（選所有適合的）
A nurse is caring for a client post-thyroidectomy. Which assessment findings should the nurse report to the surgeon immediately? (Select all that apply.)
- AInspiratory stridor✓ 正解吸氣性喘鳴
- BHoarseness when speaking說話時聲音沙啞
- CPositive Chvostek's sign✓ 正解陽性 Chvostek 徵象
- DSlight serosanguineous drainage少量漿液血性滲出液
- ENeck swelling and tracheal deviation✓ 正解頸部腫脹和氣管偏移
— Explanation · 中文詳解 —
甲狀腺切除術後需優先評估呼吸道與副甲狀腺功能。吸氣性喘鳴（stridor）暗示喉頭水腫或氣道阻塞；頸部腫脹伴氣管偏移則高度懷疑血腫壓迫；Chvostek徵象表示低血鈣，可能引發喉頭痙攣。聲音嘶啞（hoarseness）可能為喉返神經受損，雖需注意但未達立即致死等級；少量漿液血性引流屬正常術後現象。
Inspiratory stridor, neck swelling with tracheal deviation, and a positive Chvostek’s sign indicate life-threatening airway obstruction, hematoma compression, and hypocalcemia, respectively. These findings require immediate surgical notification, whereas hoarseness and minor drainage are expected post-operative findings.
✦ 台美臨床差異
美國護理師在呼吸急促時可更主動執行氣道備位準備；台灣較依賴醫師決定是否重新進手術室探查。