— 生理適應 · MEDIUM · MCQ —
護理師正在評估一位急性氣喘發作的病人。哪項發現表明有最嚴重的氣道阻塞？
A nurse is assessing a client experiencing an acute asthma exacerbation. Which finding indicates the most severe obstruction?
- AUse of accessory muscles for breathing使用輔助肌肉呼吸
- BWheezing heard on inspiration and expiration吸氣和呼氣時均可聽到喘鳴聲
- CDiminished breath sounds with prolonged expiratory phase✓ 正解呼吸音減弱伴隨呼氣期延長
- DClient speaking in full sentences客戶能說完整的句子
— Explanation · 中文詳解 —
嚴重的氣道阻塞可能導致氣流明顯減少，甚至聽不到喘鳴聲（wheezing），僅能聽到呼吸音微弱，且呼氣時間顯著延長。此時病人處於極度危險狀態，可能即將發生呼吸衰竭。選項 B、D、A 雖表示氣喘，但相較於呼吸音減弱，代表阻塞更為嚴重。
Severe airway obstruction may lead to markedly decreased airflow, to the point that wheezing is no longer heard, with only faint breath sounds and a significantly prolonged expiratory phase. At this point, the client is in extreme danger and may be imminently developing respiratory failure. Although options B, D, and A indicate asthma, diminished breath sounds represent more severe obstruction.
✦ 台美臨床差異
美國急診室對氣喘發作的處理流程（如早期給予支氣管擴張劑和類固醇）已高度標準化；台灣也遵循類似原則，但部分地區的醫療資源與急診壅塞狀況可能影響處置速度。