— 生理適應 · EASY · MCQ —
護理師評估一位疑似氣胸的病人。哪項發現最符合此疾病的特徵？
A nurse is assessing a client with a suspected pneumothorax. Which finding is most characteristic of this condition?
- ADullness upon percussion of the affected side患側叩診呈濁音
- BIncreased breath sounds on the affected side患側呼吸音增強
- CTracheal deviation toward the affected side氣管向患側偏移
- DAbsent or diminished breath sounds on the affected side✓ 正解患側呼吸音消失或減弱
— Explanation · 中文詳解 —
氣胸是指空氣進入胸膜腔導致肺部塌陷，因此患側聽不到呼吸音（D）。氣胸在叩診時會呈現過度反響（Hyperresonance），而非濁音（D，濁音見於胸水）。氣管偏移（C）通常發生在張力性氣胸且偏向健側。
Pneumothorax occurs when air enters the pleural space and causes lung collapse, so breath sounds are absent on the affected side (D). On percussion, pneumothorax produces hyperresonance rather than dullness (D, which is seen in pleural effusion). Tracheal deviation (C) typically occurs in tension pneumothorax and shifts toward the unaffected side.
✦ 台美臨床差異
氣胸評估（I-P-P-A）是台美護理師必備的身體評估技能。