# 護理師接獲四位個案的報告。護理師應先評估哪一位個案？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393675&lang=zh-tw  
> language: zh-TW  
> subject: Establishing Priorities  
> category: MOC

## 題目

護理師接獲四位個案的報告。護理師應先評估哪一位個案？

## 選項

1. 單純闌尾切除術後等待出院衛教的個案。
2. 術後 24 小時低燒且正在使用誘發性肺量計的個案。
3. 慢性背痛且要求 30 分鐘後到期止痛藥的個案。
4. 20 分鐘前開始出現新的臉部下垂與口齒不清的個案。 **✔ 正確答案**

**正確答案: 4**

## 解析

新出現的臉部下垂與構音含糊是急性中風的警示徵象，需要迅速評估並啟動緊急中風照護。具時效性的神經學變化優先於穩定的出院衛教、預期性的術後發燒，或非急性的慢性疼痛藥物定時給藥。

## 深入解析

臨床判斷
依急性變化、腦灌流威脅與時間敏感治療窗口排序。

記憶重點
新的神經缺損就是現在的問題。

## 臨床情境

實務指引
優先順序需考量氣道、呼吸、循環、急性神經變化與時間敏感處置。

注意
不要選最吵或最容易處理者，要選快速傷害風險最高者。

## 重要概念

- **中風** — 腦血流急性中斷，可造成突然無力、臉部下垂、語言改變或視覺症狀。
- **優先順序** — 判斷哪個個案需求需要立即評估或介入的護理過程。
- **神經學評估** — 針對意識、語言、肌力、瞳孔與其他神經系統發現的聚焦評估。

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