— 生理適應 · HARD · SATA —
護理師正在照護一位疑似肺栓塞的病患，預期會評估到哪些臨床表徵？（選所有適合的）
A nurse is caring for a client with a suspected pulmonary embolism. Which clinical manifestations should the nurse expect to assess? (Select all that apply.)
- ASudden onset of dyspnea✓ 正解突發性呼吸困難
- BPleuritic chest pain✓ 正解胸膜性胸痛
- CBradycardia心搏過緩
- DApprehension and anxiety✓ 正解憂慮和焦慮
- EHemoptysis✓ 正解咳血
— Explanation · 中文詳解 —
肺栓塞導致肺部氣體交換障礙，典型表現為突發性呼吸困難、胸膜炎性胸痛（吸氣時加劇）、焦慮不安，若肺部組織受損可能出現咳血。心跳通常會代償性增快（心搏過速）而非過緩。此類病患需要立即供氧並進行抗凝血治療，防止栓塞持續擴大。
Pulmonary embolism typically presents with sudden dyspnea due to impaired gas exchange, pleuritic chest pain from pleural inflammation, apprehension reflecting hypoxia, and hemoptysis resulting from pulmonary infarction. Tachycardia, not bradycardia, is the expected compensatory response to hypoxemia.
✦ 台美臨床差異
在美國急診與病房，針對肺栓塞的早期預警系統（PEWS）應用廣泛；台灣多依賴護理師的臨床經驗觀察與醫師診斷。