— 生理適應 · HARD · MCQ —
一位 55 歲高血壓病史個案，主訴突然出現撕裂般的胸痛並放射至背部。下列哪項評估發現需要立即護理介入？
A 55-year-old client with a history of hypertension reports a sudden, severe "tearing" chest pain radiating to the back. Which assessment finding requires immediate nursing intervention?
- ARespiratory rate of 22 breaths per minute呼吸頻率為每分鐘 22 次
- BHeart rate of 98 beats per minute心率為每分鐘 98 次
- CBlood pressure reading of 180/100 mmHg血壓讀數為 180/100 mmHg
- DPulse deficit between upper extremities✓ 正解雙上肢脈搏存在差異
— Explanation · 中文詳解 —
此個案表現典型主動脈剝離（Aortic Dissection）症狀。脈搏不對稱（Pulse deficit）暗示血管剝離影響了主動脈弓分支，導致遠端灌流不均，這是心血管外科急症，需立即準備手術以防止破裂。
A pulse deficit between upper extremities indicates that the aortic dissection may involve the aortic arch branches, causing unequal blood flow to the arms. This finding is a medical emergency requiring immediate surgical intervention to prevent rupture or further vascular compromise. Other symptoms like tachycardia or hypertension are common but less specific for immediate surgical urgency.
✦ 台美臨床差異
美國護理師在接獲疑似剝離警訊時，通常立即啟動 Rapid Response Team；台灣流程多先通知主治醫師會診外科。