# 72歲病人因突然右側無力與失語至急診。家屬陳述症狀始於2小時前。BP 168/92。護理師預期中風路徑之下一優先步驟為何？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=373516&lang=zh-tw  
> language: zh-TW  
> subject: NCLEX-RN  
> category: ROR

## 題目

72歲病人因突然右側無力與失語至急診。家屬陳述症狀始於2小時前。BP 168/92。護理師預期中風路徑之下一優先步驟為何？

## 選項

1. 立即給予aspirin 325 mg PO以預防進一步血栓形成。
2. 啟動中風團隊並於到達25分鐘內取得非顯影頭部CT以於任何溶栓決定前排除出血。 **✔ 正確答案**
3. 於進一步評估前以IV labetalol積極將BP降至≤ 120/80。
4. 預約晨間頭部MRI以確認診斷。

**正確答案: 2**

## 解析

急性缺血性中風路徑：啟動中風團隊、25分鐘內非顯影頭部CT(於溶栓前必須排除出血)、4.5小時窗內目標door-to-needle IV alteplase ≤60分鐘。tPA決定前不可給aspirin(1) — 會延誤或禁忌alteplase。缺血性中風於tPA前BP容許至~185/110(3 — 過度降低可能使梗塞擴大)。MRI非初次檢查(4) — 非顯影CT較快且足以排除出血。

## 深入解析

時間就是腦。Alteplase之door-to-needle目標≤60分鐘。tPA前容許性高血壓至~185/110 — 僅高於此時降BP。Aspirin於tPA後24小時方給。經典NCLEX陷阱為急著給aspirin或急降BP — 兩者皆惡化結果。

## 臨床情境

**72歲，突發右側無力與失語2小時前**。BP 168/92、HR 88、BG 110。家屬確認last-known-well為2小時前。疑**急性缺血性中風**；tPA時窗仍開。

## 重要概念

- **FAST評估** — Face droop、Arm weakness、Speech difficulty、Time of last known well — 社區與EMS中風篩檢。
- **tPA / alteplase時窗** — 自last-known-well起4.5小時內IV alteplase適用(3-4.5h擴展標準有額外排除)。
- **容許性高血壓(tPA前)** — alteplase前容許BP至~185/110；積極降BP可能擴大缺血半暗帶。

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