— 照護管理 · MEDIUM · MCQ —
護理師正在收納一位因髖部骨折而有劇烈疼痛及活動受限的病人，下列何項護理診斷最需要立即關注？
A nurse is admitting a client with severe pain and immobility due to a fractured hip. Which nursing diagnosis requires the most immediate attention?
- ARisk for deep vein thrombosis (DVT) related to immobility因活動受限導致深部靜脈栓塞 (DVT) 的風險
- BDeficient knowledge regarding post-operative care關於術後照護的知識缺乏
- CRisk for impaired skin integrity related to immobility因活動受限導致皮膚完整性受損的風險
- DAcute pain related to fracture✓ 正解與骨折相關的急性疼痛
— Explanation · 中文詳解 —
根據護理過程的 ABC（Airway, Breathing, Circulation）原則，疼痛雖然不是直接威脅生命的呼吸問題，但未經緩解的急性疼痛會導致病人交感神經興奮，進而引發心率加快、血壓升高，並限制活動意願，進而增加肺炎與 DVT 的風險。因此，優先處理急性疼痛（Acute Pain）是穩定病人狀態、促進早期復健的基礎。
Although acute pain is not directly life-threatening like airway or breathing issues, unmanaged pain triggers sympathetic nervous system excitation, leading to tachycardia, hypertension, and immobility. This physiological stress increases the risk of complications such as pneumonia and deep vein thrombosis. Therefore, prioritizing acute pain management stabilizes the patient's condition and facilitates early rehabilitation.