# 一位患有鐮狀細胞疾病的個案出現嚴重腿部疼痛及脫水徵象。護理師應優先進行哪項處置？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397265&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

一位患有鐮狀細胞疾病的個案出現嚴重腿部疼痛及脫水徵象。護理師應優先進行哪項處置？

## 選項

1. 在疼痛的肢體上使用冷敷。
2. 鼓勵下床活動直到疼痛減輕。
3. 依醫囑給予止痛藥和靜脈輸液。 **✔ 正確答案**
4. 限制液體攝入以預防水腫。

**正確答案: 3**

## 解析

血管阻塞危象的處理重點在於疼痛控制、補充水分、必要時給氧以及治療誘發因素。冷敷可能加劇血管收縮，而在劇烈疼痛時下床活動可能增加耗氧量。當存在脫水情況時，限制液體會增加鐮狀細胞形成的風險。

## 深入解析

臨床判斷
運用個案線索、時機、檢驗數據及安全風險，選出最符合「鐮狀細胞血管阻塞危象」情境的回應。

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，而非單獨的回憶。

## 臨床情境

臨床實務指引
針對「鐮狀細胞血管阻塞危象」，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順序或安全性時，切勿僅根據單一線索選擇行動。

## 重要概念

- **鐮狀細胞疾病** — 一種遺傳性疾病，紅血球會變成鐮刀狀並阻塞血流。
- **血管阻塞危象** — 因鐮狀細胞阻塞小血管而引起的疼痛。
- **補充水分** — 用於維持循環並減少鐮狀細胞形成誘因的液體支持。

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