— 降低風險 · HARD · MCQ —
一位敗血症病人，下列哪項評估結果最關鍵？
A nurse is caring for a client with a diagnosis of sepsis. Which assessment finding is the most critical?
- AAltered mental status✓ 正解意識狀態改變
- BIncreased WBC count白血球計數增加
- CElevated temperature體溫升高
- DTachycardia心跳過速
— Explanation · 中文詳解 —
敗血症病人的精神狀態改變（如意識不清、混亂）是組織灌流不足導致腦部缺氧的指標，也是器官功能衰竭（SOFA score 核心）的早期徵兆。相較於發燒或白血球升高，意識改變對預後與生存率的影響最為直接且致命。
Altered mental status is the most critical assessment finding in a client with sepsis because it indicates poor cerebral perfusion and potential organ failure. While fever, leukocytosis, and tachycardia are common signs of infection, changes in consciousness are early indicators of severe systemic compromise and significantly impact prognosis.
✦ 台美臨床差異
美台對敗血症的監測皆強調「早期發現」，台灣亦導入快速篩檢流程，護理師角色關鍵。