護理師照護一位疑似張力性氣胸的病人。護理師應預期哪項臨床表現？
The nurse is caring for a client with a suspected tension pneumothorax. Which clinical manifestation should the nurse anticipate?
- ABradycardia and hypertension心搏過緩與高血壓
- BFlattened neck veins頸靜脈塌陷
- CTracheal deviation toward the unaffected side✓ 正解氣管偏向健側
- DTracheal deviation toward the affected side氣管偏向患側
張力性氣胸（Tension pneumothorax）是一種危及生命的緊急情況，當空氣進入胸膜腔後無法排出，導致胸膜腔內壓力持續升高。這種壓力會將縱隔腔（mediastinum）結構（包括心臟、大血管和氣管）推向未受影響的一側，進而壓迫健側肺臟和影響心臟回流，造成嚴重的呼吸和循環功能障礙。核心概念是了解胸腔內壓力變化對解剖結構的影響。護理師必須能識別這種情況的典型臨床表現，以便及早通知醫師進行緊急減壓處理，如針刺減壓（needle decompression）。
Tension pneumothorax is a life-threatening emergency where air entering the pleural space cannot escape, causing rising intrapleural pressure. This pushes mediastinal structures (heart, great vessels, trachea) toward the unaffected side, compressing the contralateral lung and impeding venous return. The nurse must recognize this classic late sign to prompt emergency decompression (e.g., needle thoracostomy).
美國護理師需識別此徵象以協助立即進行針頭減壓（Needle decompression）；台灣多由醫師執行評估與處置。