— 生理適應 · EASY · MCQ —
一位疑有氣胸的病人，下列哪項評估發現最符合此診斷？
A nurse is assessing a client with a suspected pneumothorax. Which assessment finding is most characteristic of this condition?
- AIncreased tactile fremitus on the affected side患側觸覺震顫增強
- BAbsence of breath sounds on the affected side✓ 正解患側呼吸音消失
- CPresence of a friction rub出現摩擦音
- DDullness upon percussion over the affected area患處叩診呈濁音
— Explanation · 中文詳解 —
氣胸（Pneumothorax）是指肋膜腔積氣，導致肺部塌陷。由於空氣阻隔，聽診患側呼吸音會消失或減弱，叩診呈現過度回音（Hyper-resonance），觸覺震顫消失。A、D 多見於肺炎或積水。摩擦音則多與肋膜炎有關。
In pneumothorax, air in the pleural space causes lung collapse on the affected side. Auscultation reveals absent or diminished breath sounds, percussion is hyper-resonant, and tactile fremitus is decreased. Dullness and increased fremitus indicate consolidation or effusion, while a friction rub is characteristic of pleurisy.
✦ 台美臨床差異
兩地護理師皆接受過聽診訓練，但在臨床報告時台灣護理師較少在護理紀錄書寫具體的聽診發現。