# 一位懷孕32週的個案主訴劇烈頭痛及眼前出現亮點。護理師應給予何種指示？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397170&lang=zh-tw  
> language: zh-TW  
> subject: Lifestyle Choices  
> category: HPM

## 題目

一位懷孕32週的個案主訴劇烈頭痛及眼前出現亮點。護理師應給予何種指示？

## 選項

1. 在暗室休息，並於下次產檢時提及。
2. 今天就立即尋求評估。 **✔ 正確答案**
3. 增加每日鈉攝取量。
4. 服用成藥去充血劑。

**正確答案: 2**

## 解析

懷孕期間出現劇烈頭痛及視力變化是警訊，需要立即評估是否為子癇前症或其他併發症。等到下次產檢可能延誤治療。增加鈉攝取或服用去充血劑無法處理此風險。

## 深入解析

臨床判斷
利用個案線索、時間點、檢驗數據及安全風險，選擇最符合懷孕警訊的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX考題獎勵基於線索的優先思考，而非單獨的記憶。

## 臨床情境

臨床實務指引
針對懷孕警訊，將完整的線索模式與個案當前的穩定性、醫囑數據及預期的護理範圍進行比較。

注意
當完整情境改變了優先次序或安全性時，不要僅根據單一線索選擇行動。

## 重要概念

- **子癇前症** — 一種妊娠併發症，涉及高血壓及可能的器官影響。
- **視力變化** — 一種神經學警訊症狀，可能發生於嚴重的妊娠併發症。
- **產前照護** — 懷孕期間的醫療照護，以監測母體和胎兒的健康。

## 相同主題題目

- [One hour after birth, a postpartum client has heavy lochia and a boggy uterus above the um…](https://mymerci.kr/pages/nclex_q.php?qn_id=393888&lang=zh-tw)
- [A pregnant client at 34 weeks gestation reports a severe headache and blurred vision. The …](https://mymerci.kr/pages/nclex_q.php?qn_id=394058&lang=zh-tw)
- [A pregnant client at 34 weeks gestation reports a severe headache and blurred vision. The …](https://mymerci.kr/pages/nclex_q.php?qn_id=394059&lang=zh-tw)
- [The nurse teaches parents of a 3-day-old newborn about jaundice. Which finding should the …](https://mymerci.kr/pages/nclex_q.php?qn_id=394157&lang=zh-tw)
- [A pregnant client at 32 weeks reports a severe headache and visual spots. Which instructio…](https://mymerci.kr/pages/nclex_q.php?qn_id=397171&lang=zh-tw)
- [A parent of a 2-day-old newborn asks why the baby's skin looks yellow. Which response shou…](https://mymerci.kr/pages/nclex_q.php?qn_id=397285&lang=zh-tw)
- [A breastfeeding client has mastitis and asks whether to stop feeding from the affected bre…](https://mymerci.kr/pages/nclex_q.php?qn_id=397341&lang=zh-tw)
- [A breastfeeding client has mastitis and asks whether to stop feeding from the affected bre…](https://mymerci.kr/pages/nclex_q.php?qn_id=397342&lang=zh-tw)

## 以其他語言閱讀

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=397170&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=397170&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=397170&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=397170&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=397170&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。_