# 護理師在個案下肢石膏固定兩小時後進行評估。哪些發現需要立即追蹤？請標示與急性腔室症候群相關的發現。 > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=556754&lang=zh-tw > language: zh-TW > subject: Medical Emergencies > category: PA ## 題目 護理師在個案下肢石膏固定兩小時後進行評估。哪些發現需要立即追蹤？請標示與急性腔室症候群相關的發現。 | 評估項目 | 目前發現 | | --- | --- | | 疼痛 | 小腿疼痛為 9/10，靜脈注射鴉片類藥物及小心抬高後仍持續。 | | 微血管回填 | 每個腳趾微血管回填時間為兩秒，膚色與前次檢查相同。 | | 腫脹 | 骨折處中度腫脹，自兩小時前上石膏以來未增加。 | | 被動活動 | 被動伸展大腳趾引起石膏深處劇烈疼痛。 | | 脈搏 | 足背動脈仍可觸及、規則且與對側足部相同。 | | 感覺 | 個案表示患側足部腳趾及足背新發刺痛感。 | | 皮膚 | 瘀傷仍侷限於骨折處，未擴散至標記邊界外。 | | 運動 | 個案無法像前次評估時抬起大腳趾。 | | 溫度 | 腳趾溫暖、粉紅，且與未受傷足部皮膚溫度一致。 | ## 解析 與預期不成比例的疼痛、被動伸展時疼痛、新發感覺異常及新發運動無力，都暗示腔室壓力升高。可觸及的脈搏並不能排除此種威脅肢體的急症。 ## 深入解析 快速解答 立即追蹤：治療後仍劇烈疼痛、被動活動腳趾時疼痛、新發刺痛感及新發腳趾無力。這些發現暗示壓力升高，可能傷害肌肉與神經。 為什麼這是正確的 急性腔室症候群會造成超乎預期的疼痛、藥物或抬高患肢無法緩解的疼痛、感覺改變及無力。[1]等待脈搏消失並不安全，因為在無脈搏出現前組織傷害可能已進展。 簡單比喻或心智圖像 想像腫脹發生在無法擴張的硬殼行李箱內。壓力升高時，柔軟內容物與線路受到擠壓；線路就是神經與血液供應。此圖像說明緊迫性，但不能取代壓力測量或外科評估。 記憶掛鉤 疼痛、被動伸展痛、針刺感與肌力喪失代表壓力。 NCLEX 決策規則 當石膏下疼痛加劇且伴隨感覺或運動改變時，要想到腔室症候群；立即進行神經血管評估並通報，不要等到脈搏消失。 為什麼其他選項是錯的 微血管回填時間兩秒、腫脹未變、足背動脈可觸及、局部瘀傷及腳趾溫暖都是有用的觀察，但無法抵銷所選的早期警訊模式。僅持續常規再評估會延誤確定性評估。參考文獻 - [1]MedlinePlus: Compartment SyndromeU.S. National Library of Medicine - [2]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing ## 相同主題題目 - [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=zh-tw) - [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=zh-tw) - [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=zh-tw) - [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=zh-tw) - [A 68-year-old client is admitted to the emergency department with suspected sepsis from a …](https://mymerci.kr/pages/nclex_q.php?qn_id=363987&lang=zh-tw) - [A nurse is caring for an adult client in the emergency department who is suspected to have…](https://mymerci.kr/pages/nclex_q.php?qn_id=363993&lang=zh-tw) - [A nurse is teaching a 72-year-old client with chronic heart failure (reduced ejection frac…](https://mymerci.kr/pages/nclex_q.php?qn_id=366202&lang=zh-tw) - [A nurse is caring for an adult client admitted with diabetic ketoacidosis. Laboratory resu…](https://mymerci.kr/pages/nclex_q.php?qn_id=366294&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=556754&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=556754&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=556754&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=556754&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=556754&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。_