— 生理適應 · MEDIUM · MCQ —
一位病人正處於哮喘急性發作，護理師的首要評估項目為？
A client is experiencing an acute asthma attack. What would be the nurse's first priority assessment?
- ASpO2 level血氧飽和度 (SpO2) 數值
- BRespiratory rate呼吸頻率
- CLung sounds肺部聽診音
- DAbility to speak in full sentences✓ 正解能否完整說出一句話的能力
— Explanation · 中文詳解 —
哮喘發作時，病人的說話能力是判斷呼吸窘迫嚴重程度最直接的臨床指標（即呼吸功能受損程度）。若無法講完整句子，代表呼吸肌疲勞或氣道嚴重阻塞，預示呼吸衰竭風險。聽診、呼吸次數與血氧雖重要，但說話能力直接反映氣道受限程度，是臨床第一線判斷重點。
During an acute asthma attack, the client's ability to speak is the most direct clinical indicator of respiratory distress severity. Inability to complete a sentence indicates respiratory muscle fatigue or severe airway obstruction and impending respiratory failure. Lung sounds, respiratory rate, and SpO2 are important but speech directly reflects the degree of airflow limitation and is the first-line clinical judgment.
✦ 台美臨床差異
美國護理師在現場判斷呼吸窘迫時非常依賴病人的言語敘述模式作為 triage 的依據，台灣護理人員亦受過此教育，但在臨床評估指標上會較多使用輔助儀器。