— 生理適應 · HARD · MCQ —
一位 55 歲高血壓病史病人，主訴突發性、劇烈「撕裂感」胸痛並放射至背部。下列何項評估發現最令人擔憂？
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?
- AMild diaphoresis and nausea輕微盜汗與噁心
- BA heart rate of 95 beats per minute心跳速率為每分鐘 95 次
- CBlood pressure discrepancy between the left and right arms✓ 正解左右手臂血壓差異
- DA respiratory rate of 22 breaths per minute呼吸速率為每分鐘 22 次
— Explanation · 中文詳解 —
撕裂感胸痛放射至背部是主動脈剝離（Aortic dissection）的典型徵兆，屬於致命性血管急症。兩側手臂血壓不對稱（>20 mmHg）是因為剝離影響主動脈弓及其分支的血流量，這是診斷該病極具價值的臨床發現。護理師必須對此徵兆保持極高警覺，立即通知醫師並準備緊急電腦斷層與手術評估，否則死亡風險極高。
A blood pressure discrepancy between arms is highly concerning as it suggests unequal perfusion caused by an aortic dissection flap obstructing arterial branches. This finding, combined with tearing chest pain radiating to the back, strongly supports the diagnosis of this life-threatening vascular emergency.