— 生理適應 · HARD · MCQ —
一位 55 歲高血壓病史病人主訴胸部有撕裂感並放射至背部。護理師的優先處置為何？
A 55-year-old client with a history of hypertension reports a sudden, severe "tearing" sensation in the chest radiating to the back. What is the nurse's priority action?
- AAssess blood pressure in both arms and auscultate for a murmur✓ 正解測量雙側手臂的血壓並聽診是否有雜音
- BObtain an EKG to rule out myocardial infarction進行心電圖檢查以排除心肌梗塞
- CPrepare the client for an emergency coronary angiography準備病人接受緊急冠狀動脈攝影
- DAdminister nitroglycerin as prescribed for chest pain依醫囑給予硝酸甘油以緩解胸痛
— Explanation · 中文詳解 —
撕裂性疼痛、放射至背部是主動脈剝離的典型徵兆。量測雙側上肢血壓的顯著差異（>20 mmHg）是鑑別診斷的關鍵依據，聽診新出現的舒張期心雜音可能有主動脈瓣逆流。此時嚴禁使用硝酸甘油，因血管擴張會加重主動脈壁壓力。心肌梗塞雖需鑑別，但主動脈剝離的緊急性更高。
The nurse should assess blood pressure in both arms and auscultate for murmurs because asymmetry and new heart sounds are hallmark signs of aortic dissection. This assessment is prioritized over an EKG or nitroglycerin administration, which could worsen the condition by causing vasodilation.
✦ 台美臨床差異
台灣醫學中心急診分流對於主動脈剝離多採 CT 優先確診；美國護理師在接獲此類主訴時，會立即呼叫專科醫師介入評估風險。