# 護理師接到四位個案的報告。應首先評估哪一位個案？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394076&lang=zh-tw  
> language: zh-TW  
> subject: Establishing Priorities  
> category: MOC

## 題目

護理師接到四位個案的報告。應首先評估哪一位個案？

## 選項

1. 一位有胸悶、冒冷汗和噁心的個案 **✔ 正確答案**
2. 一位慢性關節炎個案請求協助拿取餐盤
3. 一位預定出院、需要藥物衛教的個案
4. 一位有失眠病史的個案昨晚睡了 4 小時

**正確答案: 1**

## 解析

胸悶伴隨冒冷汗和噁心，暗示可能為急性冠心症，需要立即評估。協助用餐、失眠和出院衛教雖然重要，但較不急迫。使用 ABCs、急性變化及潛在不穩定性來排列優先順序。

## 深入解析

臨床判斷
優先順序排列傾向於急性、可能危及生命的變化，而非常規需求。

記憶提示
胸悶加上冒冷汗等於優先評估。

## 臨床情境

臨床實務指引
急性冠心症狀可能包括胸部不適、冒汗、噁心、呼吸急促，以及輻射至手臂、下顎或背部的疼痛。

注意事項
在評估可能的心肌缺血前，不要等待典型的劇烈胸痛出現。

## 重要概念

- **檢傷分類 (Triage)** — 根據緊急性和風險對個案進行分類，以決定照護優先順序。
- **盜汗** — 可能因疼痛、休克或心臟缺血而發生的大量出汗。
- **急性冠心症** — 由心臟血流突然減少所引起的一系列病症。

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