— 安全與感染控制 · MEDIUM · MCQ —
護理師在內外科病房進行病人評估，下列哪位病人應優先處理？
A nurse is prioritizing patient safety in a medical-surgical ward. Which client should the nurse assess first?
- AA client with a new onset of confusion and restlessness✓ 正解出現新發意識混亂與煩躁不安的病人
- BA client complaining of 4/10 intensity pain主訴疼痛強度為4/10的病人
- CA client who has a dressing change scheduled for the next hour預約下一小時換藥的病人
- DA client with a blood pressure of 140/90 mmHg血壓為140/90 mmHg的病人
— Explanation · 中文詳解 —
神經學症狀的改變（如突發意識混亂或躁動）通常暗示著急性缺氧、低血糖、敗血症或中風等緊急生理問題，屬於 ABC 中「神經系統」的失代償。血壓偏高與輕度疼痛為次要優先，換藥屬於常規護理，應排在評估生命跡象穩定後。
Altered mental status, such as sudden confusion or restlessness, is a critical indicator of physiological instability like hypoxia, hypoglycemia, or sepsis, making it the highest priority under ABCs. Other options involve stable conditions or routine tasks that do not pose an immediate threat to life.
✦ 台美臨床差異
台美優先級評估原則相似，皆遵循 ABC (Airway, Breathing, Circulation) 與 Maslow 需求層次。