— 生理適應 · MEDIUM · MCQ —
護理師照護一位發生心臟衰竭的心肌梗塞病人。哪項評估發現最能指示左心衰竭？
A nurse is caring for a client with a history of myocardial infarction (MI) who develops heart failure. Which assessment finding is most indicative of left-sided heart failure?
- AJugular venous distention頸靜脈怒張
- BBibasilar crackles✓ 正解雙肺底囉音
- CHepatomegaly肝腫大
- DPeripheral edema周邊水腫
— Explanation · 中文詳解 —
左心衰竭意味著左心室無法有效將血液泵入全身，導致血液回流至肺部，引起肺部鬱血。肺部鬱血的表現包括呼吸困難、端坐呼吸和肺底囉音 (crackles)。右心衰竭則主要影響體循環，導致頸靜脈怒張、周邊水腫和肝臟腫大。
Left-sided heart failure means the left ventricle cannot effectively pump blood to the body, causing blood to back up into the lungs and producing pulmonary congestion. Pulmonary congestion manifests as dyspnea, orthopnea, and bibasilar crackles. Right-sided heart failure mainly affects the systemic circulation, causing jugular venous distention, peripheral edema, and hepatomegaly.
✦ 台美臨床差異
美國心臟內科護理師會指導病人自我監測心臟衰竭症狀；台灣則多由醫師開立處方，護理師衛教病人用藥和回診重要性。