— 生理適應 · HARD · MCQ —
病人診斷為張力性氣胸。護理師應預期出現哪種臨床體徵？
A client is diagnosed with a tension pneumothorax. Which clinical sign should the nurse expect?
- ATracheal deviation toward the unaffected side✓ 正解氣管偏向未患病側
- BIncreased breath sounds on the affected side患側呼吸音增強
- CBradycardia and hypertension心搏過緩及高血壓
- DTracheal deviation toward the affected side氣管偏向患側
— Explanation · 中文詳解 —
張力性氣胸 (Tension pneumothorax) 是一種危及生命的急症，由於胸腔內空氣持續積聚，但無法排出，導致胸膜腔壓力不斷升高。這種高壓不僅會使受影響的肺臟完全塌陷，還會將縱膈腔 (mediastinum)（包括氣管、心臟和大血管）推向未受影響的健側。縱膈腔的偏移會壓迫健側肺部和心臟，嚴重阻礙靜脈回流，導致心輸出量 (cardiac output) 驟降，引起休克。護理師必須能快速辨識其臨床體徵，以便立即協助進行針刺減壓或胸腔引流，挽救病人生命。
In a tension pneumothorax, accumulating air increases intrathoracic pressure, causing the mediastinum and trachea to deviate toward the unaffected side. This shift compresses the healthy lung and impairs venous return, leading to shock, making tracheal deviation a key clinical sign requiring immediate intervention.