— 照護管理 · MEDIUM · SATA —
氣喘病人出現哪些評估發現，護理師應優先通知醫師？（選所有適合的）
Which assessment findings for a client with asthma should the nurse prioritize reporting to the provider? (Select all that apply.)
- ADiminished breath sounds throughout the lungs✓ 正解雙肺呼吸音減弱
- BIncreased respiratory rate to 28 breaths/min呼吸頻率增加至每分鐘 28 次
- CAudible wheezing on expiration呼氣時可聞及哮鳴音
- DInability to speak in full sentences✓ 正解無法說完整句話
- ERestlessness and confusion✓ 正解煩躁不安與意識混亂
— Explanation · 中文詳解 —
氣喘急性發作時，聽診呼吸音消失（沈默肺）代表氣道嚴重阻塞，伴隨無法說話與意識狀態改變（躁動、混亂），這些都是瀕臨呼吸衰竭的危險訊號。哮鳴音（Wheezing）雖然明顯，但沈默肺（Silent Chest）的風險更高。
In acute asthma exacerbation, diminished (or absent) breath sounds—'silent chest'—indicates such severe airflow obstruction that no air movement is detectable and signals impending respiratory failure. Inability to speak in full sentences and altered mental status (restlessness, confusion) both reflect critical hypoxia/hypercarbia. Tachypnea and audible wheezing are expected and concerning but less ominous than the silent chest and mental status changes.
✦ 台美臨床差異
臨床上兩地對於氣喘分級治療指引皆遵循 GINA 指引，重點皆在於辨識呼吸衰竭徵兆。