一位護理師正在管理一位氣喘急性惡化的病人。哪些評估發現需要立即介入？（選所有適合的）
A nurse is managing a client with acute exacerbation of asthma. Which assessment findings require immediate intervention? (Select all that apply.)
- AUse of accessory muscles to breathe.✓ 正解使用輔助肌肉呼吸。
- BPeak expiratory flow rate (PEFR) is 70% of personal best.峰值呼氣流速（PEFR）為個人最佳值的 70%。
- CClient is able to speak in short sentences.病人能說短句。
- DDiminished or absent breath sounds.✓ 正解呼吸音減弱或消失。
- EHeart rate of 110 beats/min.心率 110 次/分。
選項 A（使用輔助呼吸肌）和 D（呼吸音減弱或消失）均指示嚴重的呼吸窘迫，可能面臨呼吸衰竭。輔助肌使用表示病人費力呼吸；呼吸音減弱或消失提示嚴重的支氣管收縮或氣道阻塞。選項 B（PEFR 70%）屬中度惡化，C（可說短句）表示情況尚可，E（心率 110）雖快，但若無其他嚴重症狀，相對較不緊急。
Use of accessory muscles and diminished or absent breath sounds both indicate severe respiratory distress and impending respiratory failure—they require immediate intervention. A PEFR of 70% indicates moderate exacerbation (needs treatment but not emergency intervention); the ability to speak in short sentences indicates relatively preserved ventilation; tachycardia is common but less critical than the airway findings.
兩地對氣喘急性惡化評估標準一致。美國有較多標準化評估工具；台灣護理師依臨床經驗判斷，並盡快執行治療。