— 照護管理 · HARD · MCQ —
護理師在急診進行檢傷分類，哪位病人應優先評估？
A nurse is performing a triage assessment in the Emergency Department. Which client should be seen first?
- AA toddler with a high fever and a stiff neck✓ 正解患有高燒與頸部僵硬的幼兒
- BA middle-aged adult with symptoms of mild gastroenteritis有輕微腸胃炎症狀的中年成人
- CAn adolescent with a closed fracture of the wrist手腕閉鎖性骨折的青少年
- DAn elderly client with stable chronic hypertension病情穩定的慢性高血壓長者
— Explanation · 中文詳解 —
幼兒出現高燒與頸部僵硬是腦膜炎（Meningitis）的典型臨床徵象，具有高傳染性且病情惡化迅速，屬於急診檢傷分類中的「緊急」（Emergent）等級，需立刻隔離與治療。骨折、腸胃炎、慢性高血壓相對穩定。
A toddler presenting with high fever and a stiff neck exhibits classic signs of meningitis, which is a medical emergency requiring immediate isolation and treatment. This condition is classified as emergent in triage due to its rapid progression and potential severity, unlike the other clients whose conditions are stable or less critical.
✦ 台美臨床差異
急診檢傷系統台美皆一致，但台灣護理師在面對病患家屬壓力時，需更具備堅持專業檢傷分級的溝通技巧。