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基本照護與舒適 · HARD · MCQ

一位有睡眠呼吸中止症病史的病人,在睡眠期間出現哪些評估發現需要護理介入?

Which assessment finding in a client with a history of sleep apnea indicates a need for nursing intervention during sleep?

  • AFrequent waking with a gasp
    頻繁驚醒並伴隨喘息
  • BOxygen saturation dropping to 85% during apneic episodes✓ 正解
    呼吸中止期間血氧飽和度降至 85%
  • CRestlessness during REM sleep
    快速眼動睡眠期間躁動不安
  • DSnoring occurring throughout the night
    整夜持續打呼
Explanation · 中文詳解

睡眠呼吸中止症(sleep apnea)病人常有打呼與睡眠中驚醒的症狀,這主要與氣道阻塞導致的間歇性缺氧有關。在所有選項中,血氧濃度(SpO2)下降至 85% 是嚴重的生理性損害指標,代表組織氧合不足,這會增加心臟負荷與心律不整風險,屬於必須立即介入的臨床危急狀況。打呼與驚醒雖是診斷徵象,但血氧過低直接威脅病人生命安全,優先級最高。

Clients with sleep apnea often experience snoring and waking from sleep, primarily related to intermittent hypoxia caused by airway obstruction. Among all options, a drop in oxygen saturation (SpO2) to 85% is a significant indicator of physiological compromise, representing inadequate tissue oxygenation. This increases cardiac workload and the risk of arrhythmias, and is a critical clinical situation that must be addressed immediately. Although snoring and arousals are diagnostic signs, hypoxemia directly threatens the client's life and is therefore the highest priority.

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