一位張力性氣胸的病人，哪項評估發現需要護理師立即求助？
Which assessment finding in a patient with a tension pneumothorax requires the nurse to call for immediate help?
- AHypotension and tachycardia✓ 正解低血壓與心搏過速
- BSubcutaneous emphysema皮下氣腫
- CDullness to percussion on affected side患側叩診呈濁音
- DMinimal chest wall movement胸壁活動度極小
張力性氣胸（Tension pneumothorax）為致命性急症。當胸腔內空氣持續累積且無法排出，會導致縱隔腔移位（Mediastinal shift），壓迫心臟與大血管，嚴重阻礙靜脈回流，引發阻塞性休克（Obstructive shock）。低血壓與心搏過速是心輸出量驟減的臨床徵象，若未立即介入進行減壓（如針刺減壓或胸管置入），病人將迅速進展至心跳停止。
Tension pneumothorax is a life-threatening emergency. When air continues to accumulate in the thoracic cavity and cannot escape, it causes mediastinal shift, which compresses the heart and great vessels, severely impeding venous return and leading to obstructive shock. Hypotension and tachycardia are clinical signs of a sharp drop in cardiac output. Without immediate decompression (e.g., needle decompression or chest tube placement), the client will rapidly progress to cardiac arrest.
在美國臨床環境中，若懷疑張力性氣胸，護理師應立即通知醫師或啟動快速反應小組（RRT），並準備進行緊急針刺減壓（Needle decompression），這屬於護理師在危急情況下可依據預設Protocol執行的範疇。