— 生理適應 · HARD · MCQ —
張力性氣胸的病人，哪項評估結果需要立即的護理介入？
Which assessment finding in a patient with a tension pneumothorax requires immediate nursing intervention?
- AAbsence of breath sounds on the affected side患側無呼吸音
- BDistended neck veins頸靜脈怒張
- CTracheal deviation toward the unaffected side✓ 正解氣管向未患側偏移
- DTachycardia and tachypnea心搏過速與呼吸過速
— Explanation · 中文詳解 —
張力性氣胸造成患側壓力過大，將縱膈腔推向健側，氣管偏移是嚴重且急迫的徵象。其他選項（無呼吸音、頸靜脈怒張、心搏過速）皆為氣胸常見特徵，但氣管偏移顯示縱膈腔位移，嚴重影響循環功能，是張力性氣胸最具鑑別性的危急指標。
In tension pneumothorax, the elevated pressure on the affected side pushes the mediastinum toward the unaffected side, making tracheal deviation a severe and emergent sign. The other options (absent breath sounds, jugular venous distention, and tachycardia) are common features of pneumothorax, but tracheal deviation specifically indicates mediastinal shift and severe compromise of circulation, making it the most distinguishing critical indicator of tension pneumothorax.
✦ 台美臨床差異
在美國，這類情況護理師需協助進行緊急針刺減壓；台灣則由醫師執行，護理師輔助準備器材。