# 一位下背痛加劇的個案正在等候評估。護理師應立即報告哪項新發現？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=498855&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## 題目

一位下背痛加劇的個案正在等候評估。護理師應立即報告哪項新發現？

## 選項

1. 在走廊行走後疼痛從 4 分增加到 5 分
2. 尿滯留伴隨大腿內側及會陰部麻木 **✔ 正確答案**
3. 腳趾刺痛感，改變姿勢後改善
4. 早晨起床時背部僵硬最明顯，上午逐漸緩解

**正確答案: 2**

## 解析

尿滯留合併鞍區感覺喪失，暗示馬尾神經壓迫。需要快速進行影像診斷及外科評估，因為延遲減壓可能導致永久性膀胱、腸道、性功能或下肢功能障礙。

## 深入解析

快速解答
報告尿滯留合併鞍區麻木，此為時間敏感性的脊椎急症。

為什麼這是正確的
馬尾神經壓迫會影響控制膀胱功能及會陰部感覺的薦神經。此合併發現顯示神經學缺損已超出單純背痛，需要緊急評估以進行減壓。

簡單比喻或心智圖像
馬尾神經就像脊椎底部的一束控制纜線；壓迫可能同時中斷多項功能。此比喻未指出病因，也無法取代影像檢查。

記憶掛鉤
背痛加上鞍區麻木加上尿滯留，等於緊急通報。

NCLEX 決策規則
在背痛表現中，優先處理新發生的膀胱或腸道功能障礙、鞍區感覺喪失或漸進性無力。這些危險信號顯示可能的神經根壓迫，而非一般的肌肉骨骼不適。

為什麼其他選項是錯的
輕微的活動相關疼痛增加、姿勢性刺痛及晨間僵硬值得評估，但未呈現急性薦神經衰竭的相同模式。參考文獻

- [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing

- [2]Cauda Equina SyndromeAmerican Association of Neurological Surgeons

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