一名 55 歲高血壓病史個案突發撕裂性胸痛並放射至背部。下列哪項評估結果最符合主動脈剝離？
A 55-year-old client with a history of hypertension reports a sudden, severe "tearing" chest pain radiating to the back. Which assessment finding is most concerning for an aortic dissection?
- AFlattened T-waves on the electrocardiogram心電圖上 T 波平坦
- BDifference in systolic blood pressure between the arms✓ 正解雙臂收縮壓之差
- CIncreased urinary output尿量增加
- DPresence of a loud S3 heart sound存在響亮的第三心音 (S3)
主動脈剝離會造成主動脈管腔受損，影響血流供應至單側上肢，導致兩側手臂收縮壓顯著差異（>20 mmHg）。這是診斷剝離的高度特徵性表徵。S3 多見於心衰竭，T 波平坦多為電解質異常，尿量增加非特異性症狀，故此題應優先觀察血壓不對稱性。
Aortic dissection damages the aortic lumen and affects blood flow to one upper extremity, resulting in a marked difference in systolic blood pressure between the two arms (>20 mmHg). This is a highly characteristic diagnostic finding of dissection. An S3 sound is most often seen in heart failure, flattened T waves usually indicate electrolyte abnormalities, and increased urine output is a nonspecific finding. Therefore, the nurse should prioritize assessment of blood pressure asymmetry.
美國急診護理師具備更強的主動判斷能力以啟動 CT 檢查，台灣則依賴醫師臨床評估後下達醫囑。