— 降低風險 · MEDIUM · SATA —
護理師照護一位懷疑氣胸的病人，應觀察到哪些臨床表現？（選所有適合的）
A nurse is caring for a client 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
- BTracheal deviation toward the affected side氣管向患側偏移
- CSudden sharp chest pain✓ 正解突發性尖銳胸痛
- DTachypnea✓ 正解呼吸過速
- EHyperresonance upon percussion of the affected side✓ 正解患側叩診呈過清音
— Explanation · 中文詳解 —
氣胸病人因肺葉塌陷，在患側可聽見呼吸音消失，且敲診呈現過度共鳴音（空氣積聚）。症狀通常為突發性胸痛與呼吸急促（Tachypnea）。選項 B 錯誤：氣管偏移（Tracheal deviation）通常是張力性氣胸的徵象，且偏移方向為「健側」（向對側偏移），而非患側。
Clinical findings of a pneumothorax include absent breath sounds and hyperresonance on the affected side due to air accumulation in the pleural space. Patients typically present with sudden sharp chest pain and tachypnea as the body compensates for reduced gas exchange.
✦ 台美臨床差異
美國護理師常需在緊急時協助胸管插入準備；台灣此類處置高度依賴醫師，護理師以監測呼吸狀況為主。