— 生理適應 · HARD · SATA —
病人出現心包填塞徵象。護理師預期會看到哪些發現？（選所有適合的）
A client is experiencing signs of cardiac tamponade. Which findings should the nurse expect? (Select all that apply.)
- AMuffled heart sounds✓ 正解心音遙遠
- BJugular venous distension (JVD)✓ 正解頸靜脈怒張 (JVD)
- CHypertension高血壓
- DPulsus paradoxus✓ 正解奇脈
- EBradycardia心搏過緩
— Explanation · 中文詳解 —
心包填塞的典型徵象包括 Beck's triad：心音遙遠（A）、頸靜脈怒張（B）、低血壓（非高血壓）。此外，吸氣時收縮壓下降 >10 mmHg 的奇脈（Pulsus paradoxus, D）也是重要發現。通常會出現心搏過速（代償），而非過緩。
Classic findings of cardiac tamponade include Beck's triad: muffled heart sounds (A), jugular venous distension (B), and hypotension (not hypertension). In addition, pulsus paradoxus (D), defined as an inspiratory decrease in systolic blood pressure greater than 10 mmHg, is an important finding. Tachycardia (compensatory) is typically present rather than bradycardia.
✦ 台美臨床差異
NCLEX 對於 Beck's Triad 與 Pulsus paradoxus 的考點極為常見，台灣護理師也需熟知此急症。