— 生理適應 · HARD · MCQ —
照護一位 C4 頸椎脊髓損傷患者時，下列哪項評估最重要？
Which of the following assessments is most important when caring for a client with a cervical spinal cord injury at the C4 level?
- ADeep tendon reflexes深部肌腱反射
- BBlood pressure and heart rate血壓和心率
- CRespiratory rate and breath sounds✓ 正解呼吸頻率和呼吸音
- DRange of motion in extremities四肢關節活動度
— Explanation · 中文詳解 —
C4 脊髓損傷影響膈神經控制，導致橫膈膜功能受損，病患恐有呼吸衰竭風險。因此，呼吸型態、頻率與肺音的評估為生命存續之根本。雖然血壓與心率（自律神經反射）亦重要，但呼吸支持在受傷急性期是絕對的優先項目。
A spinal cord injury at C4 affects phrenic nerve innervation, impairing diaphragm function and creating risk of respiratory failure. Assessment of respiratory pattern, rate, and breath sounds is therefore fundamental to maintaining life. Although blood pressure and heart rate (autonomic responses) are also important, respiratory support is the absolute priority in the acute phase of injury.
✦ 台美臨床差異
美國脊髓損傷中心多有專門的呼吸復健團隊；台灣臨床則依賴加護病房呼吸器輔助，護理師對脫離呼吸器的評估角色極重。