— 生理適應 · HARD · MCQ —
一位 55 歲高血壓病史的個案，主訴突然且劇烈的「撕裂感」胸痛並放射至背部。護理師應首先懷疑何種狀況？
A 55-year-old client with a history of hypertension reports a sudden, severe "tearing" chest pain radiating to the back. Which condition should the nurse suspect first?
- AAortic dissection✓ 正解主動脈剝離
- BPulmonary embolism肺栓塞
- CMyocardial infarction心肌梗塞
- DEsophageal rupture食道破裂
— Explanation · 中文詳解 —
撕裂感胸痛放射至背部是主動脈剝離的典型徵象，常見於長期高血壓控制不佳的族群。此病況屬於緊急外科急症，若未及時處理可能導致主動脈破裂、心包填塞或終末器官缺血，護理師需立即監測血壓並準備緊急輸血與手術準備。
A tearing chest pain radiating to the back is a classic sign of aortic dissection and is common in populations with long-standing poorly controlled hypertension. This condition is a surgical emergency; if not promptly managed, it may lead to aortic rupture, cardiac tamponade, or end-organ ischemia. The nurse must immediately monitor blood pressure and prepare for emergency transfusion and surgical intervention.
✦ 台美臨床差異
美台臨床皆視其為急症，但美國急診護理師在接到此症狀時會立即啟動 Massive Transfusion Protocol。