— 生理適應 · HARD · MCQ —
一位病人因疑似肺栓塞入院,下列哪項評估發現需要護理師立即採取行動?
A client is admitted with suspected pulmonary embolism. Which assessment finding requires immediate nursing action?
- ATachycardia心跳過速
- BDyspnea on exertion勞力性呼吸困難
- CHypotension✓ 正解低血壓
- DPleuritic chest pain胸膜性胸痛
— Explanation · 中文詳解 —
肺栓塞(Pulmonary Embolism, PE)的臨床表現多樣,但在護理評估中,必須區分「症狀」與「危急生命徵象」。低血壓(Hypotension)代表病人可能已出現阻塞性休克(Obstructive Shock),心輸出量嚴重不足,這是肺栓塞最致命的併發症。護理師必須優先處理會導致心搏驟停的生理失衡。
The clinical presentation of pulmonary embolism (PE) is varied, but in nursing assessment it is essential to distinguish between symptoms and life-threatening signs. Hypotension indicates that the client may already be in obstructive shock with severely reduced cardiac output, which is the most lethal complication of PE. The nurse must prioritize correction of the physiologic derangement that can lead to cardiac arrest.