# 一名72歲病人約2小時前突發左側肢體無力與口齒不清,由家屬送至急診。頭部CT無出血,NIH Stroke Scale 14分。靜脈組織纖溶酶原活化劑(tPA)給予前,護理師最須確認的評估為何? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=zh-tw > language: zh-TW > subject: Medical Emergencies > category: PA ## 題目 一名72歲病人約2小時前突發左側肢體無力與口齒不清,由家屬送至急診。頭部CT無出血,NIH Stroke Scale 14分。靜脈組織纖溶酶原活化劑(tPA)給予前,護理師最須確認的評估為何? ## 選項 1. 病人最後仍正常的確切時間 **✔ 正確答案** 2. 家族出血性疾病史 3. 12導程心電圖 4. 血糖值 **正確答案: 1** ## 解析 缺血性中風中「最後正常時間(last known well)」是決定tPA適應症的最重要因素。AHA/ASA標準: 符合條件者於最後正常時間4.5小時內靜注alteplase或tenecteplase。血糖、心電圖、出血病史亦評估,但時間窗未確認前無法決定治療。 ## 深入解析 臨床判斷 急性缺血性中風由last known well時間啟動。tPA時窗: 4.5小時(NINDS/ECASS-III)。無時間窗則無論NIH分數、血糖、心電圖均無法做溶栓決策。 記憶口訣 中風FAST + last known well — 永遠先問 韓 vs 美 AHA/ASA 4.5小時為國際標準。臺灣中風登錄(TSR)亦採同標準;大血管阻塞之血栓清除可延至24小時。 ## 臨床情境 臨床指引 2019 AHA/ASA中風指引: 靜注alteplase 0.9 mg/kg(最多90 mg)1小時,首10%於1分鐘bolus,或tenecteplase 0.25 mg/kg bolus,皆需於last known well 4.5小時內。大血管阻塞之機械式血栓清除可至6-24小時。tPA前維持血壓 <185/110。 注意 晨起發現中風以最後一次見到正常之時間為last known well。勿直接認定不適合tPA — 現代MRI影像可使部分病人時間窗延長。 ## 重要概念 - **Last known well** — 病人在無中風症狀下最後一次被確認正常的時間點。定義溶栓治療時窗的起點。晨起中風以病人最後在神經學基線狀態被觀察到的時間為準。 - **tPA (alteplase)** — 組織纖溶酶原活化劑。將纖溶酶原轉為纖溶酶,溶解纖維蛋白血栓。缺血性中風於4.5小時、無PCI時STEMI於12小時內靜注。主要風險: 顱內出血。 - **NIH Stroke Scale** — 標準化15項神經學評估,分數0-42。≥5分通常考慮再灌流;>25分因梗塞負荷大可能為IV tPA相對禁忌。 ## 相同主題題目 - [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=zh-tw) - [A 68-year-old client with COPD is admitted with shortness of breath and SpO2 86% on room a…](https://mymerci.kr/pages/nclex_q.php?qn_id=362940&lang=zh-tw) - [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=zh-tw) - [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=zh-tw) - [A nurse is caring for a client prescribed Digoxin. Which nursing action is most appropriat…](https://mymerci.kr/pages/nclex_q.php?qn_id=375157&lang=zh-tw) - [Which action should the nurse take?](https://mymerci.kr/pages/nclex_q.php?qn_id=391869&lang=zh-tw) - [A client with type 1 diabetes is awake, can swallow, and reports shakiness. The point-of-c…](https://mymerci.kr/pages/nclex_q.php?qn_id=393564&lang=zh-tw) - [A client develops wheezing, generalized hives, and blood pressure 78/42 mm Hg after receiv…](https://mymerci.kr/pages/nclex_q.php?qn_id=393725&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_