一位頸椎脊髓損傷的病人，哪項評估發現需要立即介入？
Which assessment finding in a client with a cervical spinal cord injury requires immediate intervention?
- AAbsence of bowel sounds腸音消失
- BHeart rate of 55 beats per minute心率 55 次/分
- CParalysis of the upper extremities上肢麻痺
- DSpO2 of 88% and shallow, rapid respirations✓ 正解SpO2 88% 且呼吸淺快
頸椎脊髓損傷（Spinal Cord Injury, SCI）的護理重點在於維持呼吸道通暢與呼吸功能，因頸部脊髓損傷可能波及膈神經（Phrenic nerve），導致橫膈肌麻痺。SpO2 88% 伴隨淺快呼吸代表病人已出現急性呼吸衰竭，這是導致死亡的最直接威脅（ABC 原則：Airway, Breathing, Circulation）。相較於肢體癱瘓或心搏過緩，呼吸功能受損需立即進行氧氣治療、抽痰甚至氣管內管插管。
Nursing care for cervical spinal cord injury (SCI) focuses on maintaining a patent airway and adequate respiratory function, because cervical cord injury may involve the phrenic nerve and lead to diaphragmatic paralysis. An SpO2 of 88% with shallow, rapid respirations indicates acute respiratory failure, which is the most direct threat to life (ABC principle: airway, breathing, circulation). Compared with limb paralysis or bradycardia, impaired respiratory function requires immediate oxygen therapy, suctioning, and even endotracheal intubation.