— 生理適應 · MEDIUM · MCQ —
病人發生急性張力性氣胸。護理師應預期看到哪項發現？
A client is experiencing an acute tension pneumothorax. Which finding should the nurse expect?
- ATracheal deviation toward the affected side氣管向患側偏移
- BHyperresonance on the unaffected side健側出現過度反響音
- CFlattened neck veins頸靜脈扁平
- DTracheal deviation toward the unaffected side✓ 正解氣管向健側偏移
— Explanation · 中文詳解 —
張力性氣胸（Tension Pneumothorax）是一種致命的呼吸急症，其核心病理為空氣進入胸膜腔後無法排出，導致胸膜腔內壓力不斷上升。當壓力過高時，會壓迫縱隔腔（Mediastinum），將氣管與心臟推向患側的對側（健側）。此過程會導致靜脈回流受阻（心輸出量下降）及呼吸衰竭。臨床護理首重辨識徵象並準備緊急減壓（如針刺減壓），氣管偏移是其典型且晚期的徵象。
In a tension pneumothorax, trapped air increases intrapleural pressure, pushing the mediastinum and trachea away from the affected side toward the unaffected side. This shift compromises venous return and cardiac output, making tracheal deviation a critical late sign requiring immediate intervention.