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生理適應 · MEDIUM · MCQ

一位 45 歲有高血壓病史的病人服用 lisinopril,哪項評估結果需要立即護理介入?

A 45-year-old client with a history of hypertension is prescribed lisinopril. Which assessment finding requires immediate nursing intervention?

  • ABlood pressure reading of 135/85 mmHg
    血壓讀數為 135/85 mmHg
  • BDizziness upon standing
    站立時頭暈
  • CSwelling of the tongue and lips✓ 正解
    舌頭和嘴唇腫脹
  • DMild dry cough
    輕微乾咳
Explanation · 中文詳解

血管收縮素轉換酶抑制劑(ACEI)常見副作用為乾咳,但血管水腫(Angioedema)為致命副作用,表現為舌頭、嘴唇腫脹,會造成呼吸道阻塞。此為緊急醫療狀況,需立即停藥並維護呼吸道通暢。姿勢性低血壓為藥物調整期常見現象,乾咳雖惱人但非生命威脅。

Swelling of the tongue and lips suggests angioedema, a potentially life-threatening allergic reaction associated with ACE inhibitor use like lisinopril. This condition can rapidly progress to airway obstruction, necessitating immediate nursing intervention such as stopping the medication and securing the airway. Other findings like mild dry cough or orthostatic dizziness are common side effects but are not emergencies.

✦ 台美臨床差異

美國護理師常需在給藥前評估 ACEI 副作用並與醫師討論更換 ARB;台灣健保藥物給付規範嚴格,常因咳嗽需長期更換藥物種類。

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