一名 55 歲高血壓病史病人主訴突然出現劇烈撕裂樣胸痛並放射至背部。下列何項評估結果需要立即護理干預？
A 55-year-old client with a history of hypertension reports a sudden onset of severe tearing chest pain radiating to the back. Which assessment finding requires immediate nursing intervention?
- AHeart rate of 88 beats per minute心率每分鐘 88 次
- BBlood pressure difference of 20 mmHg between the left and right arms✓ 正解左右手臂血壓相差 20 mmHg
- COxygen saturation of 96%氧氣飽和度 96%
- DRespiratory rate of 20 breaths per minute呼吸頻率每分鐘 20 次
主動脈剝離（Aortic Dissection）的典型表現為突然出現的劇烈撕裂樣胸痛放射至背部。兩臂血壓落差 >20 mmHg 是關鍵的臨床評估發現，提示剝離可能影響了鎖骨下動脈的血流，顯示病情正在惡化。這是血管外科的緊急狀況，可能導致器官缺血、心包填塞或動脈破裂，護理師需立即通知醫師並準備降壓與止痛藥物。
The classic presentation of aortic dissection is the sudden onset of severe, tearing chest pain radiating to the back. A blood pressure difference greater than 20 mmHg between the two arms is a key clinical finding, suggesting that the dissection may have affected blood flow through the subclavian artery and that the condition is worsening. This is a vascular surgical emergency that can lead to organ ischemia, cardiac tamponade, or arterial rupture; the nurse must immediately notify the physician and prepare antihypertensive and analgesic medications.