— 生理適應 · HARD · SATA —
護理師評估疑似張力性氣胸的病人，應觀察到哪些臨床表現？（選所有適合的）
A nurse is assessing a client with a suspected tension pneumothorax. Which clinical findings should the nurse expect? (Select all that apply.)
- ATracheal deviation to the unaffected side✓ 正解氣管向健側偏移
- BSudden onset of dyspnea✓ 正解突發性呼吸困難
- CHyper-resonance on percussion✓ 正解叩診呈過清音
- DBradycardia心搏過緩
- EHypotension✓ 正解低血壓
— Explanation · 中文詳解 —
張力性氣胸（tension pneumothorax）是呼吸系統急症。由於空氣進入胸膜腔卻無法排出，壓力持續升高，導致患側肺部塌陷，並將縱隔（mediastinum）推向健康側，進而壓迫大靜脈，減少靜脈回流，導致心輸出量下降，引發低血壓與心跳過速。臨床評估中，氣管偏移（tracheal deviation）是張力性氣胸的晚期標誌性徵兆，而呼吸困難、敲診呈過響音（hyper-resonance）則是空氣積聚的典型臨床發現。
Tension pneumothorax causes a medical emergency where accumulated air shifts the mediastinum, pushing the trachea to the unaffected side and compressing the vena cava. This compression reduces venous return, leading to hypotension and tachycardia, while the trapped air causes sudden dyspnea and hyper-resonance on percussion.