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生理適應 · HARD · SATA

懷疑氣胸的病人,護理師應預期看到哪些臨床表現?(選所有適合的)

A client presents with a suspected pneumothorax. Which clinical findings should the nurse expect? (Select all that apply.)

  • AAbsent breath sounds on the affected side✓ 正解
    患側呼吸音消失
  • BSudden onset of chest pain✓ 正解
    突發性胸痛
  • CTracheal deviation toward the affected side
    氣管向患側偏移
  • DHyper-resonance on percussion✓ 正解
    叩診呈過度共振音
  • EDyspnea✓ 正解
    呼吸困難
Explanation · 中文詳解

氣胸(Pneumothorax)病人因胸膜腔內累積氣體,導致肺部塌陷。臨床表現包括患側呼吸音消失(因空氣阻隔傳導)、突然胸痛(因胸膜受損)、叩診出現過度迴響(Hyper-resonance,因肺部充滿空氣)、呼吸困難(因通氣量減少)。這些表徵直接反映了胸膜腔壓力改變與肺部受損的生理病理狀況。氣管偏移通常向健側偏移,以平衡胸腔內兩側壓力。

In a patient with pneumothorax, accumulation of air in the pleural space causes lung collapse. Clinical manifestations include absent breath sounds on the affected side (air blocks transmission), sudden chest pain (due to pleural injury), hyper-resonance on percussion (because the lung is filled with air), and dyspnea (due to decreased ventilation). These findings directly reflect the pathophysiologic changes in pleural pressure and lung injury. Tracheal deviation typically occurs toward the unaffected side to balance the pressures within the two sides of the thorax.

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