— 生理適應 · MEDIUM · MCQ —
一位氣喘急性發作的病人。哪項評估發現最令人擔心？
A nurse is caring for a client experiencing an acute asthma attack. Which assessment finding is most concerning?
- AWheezing on expiration呼氣時出現喘鳴音
- BRapid respiratory rate呼吸速率加快
- CAbsent breath sounds✓ 正解呼吸音消失
- DUse of accessory muscles使用呼吸輔助肌肉
— Explanation · 中文詳解 —
氣喘發作時聽不到呼吸音（Silent chest）代表氣道嚴重阻塞，氣體無法流動，是即將呼吸衰竭的危險前兆。哮鳴音雖然令人緊張，但代表氣道仍有氣流通過；呼吸急促與使用輔助肌肉皆為氣喘的典型表現，嚴重性低於呼吸音消失。
Absent breath sounds (a 'silent chest') during an asthma exacerbation indicate severe airway obstruction with no airflow and herald impending respiratory failure. Although wheezing is alarming, it indicates that air is still moving through the airways; tachypnea and use of accessory muscles are classic asthma findings whose severity is less than that of absent breath sounds.
✦ 台美臨床差異
美台皆將「無呼吸音」視為急診危急指標，護理師需即刻啟動團隊應變。