— 生理適應 · MEDIUM · MCQ —
一位 55 歲高血壓病史個案，自述胸部出現劇烈「撕裂感」且放射至背部。護理師應懷疑哪種狀況？
A 55-year-old client with a history of hypertension reports a sudden, severe "tearing" chest pain radiating to the back. Which condition should the nurse suspect?
- ATension pneumothorax張力性氣胸
- BAortic dissection✓ 正解主動脈剝離
- CPulmonary embolism肺栓塞
- DMyocardial infarction心肌梗塞
— Explanation · 中文詳解 —
主動脈剝離（Aortic Dissection）的典型臨床表徵為突發性、劇烈且具「撕裂感（Tearing sensation）」的胸痛，並會放射至背部或肩胛骨之間。高血壓是導致血管內膜受損並產生剝離的主要風險因子。此狀況屬於心血管急症，若不即時處理，可能導致主動脈破裂或器官灌流不足，護理師需迅速識別並啟動急救機制。
The classic hallmark of aortic dissection is sudden, severe 'tearing' chest pain radiating to the back, often in clients with a history of hypertension. This condition is a cardiovascular emergency requiring immediate recognition and intervention to prevent rupture or organ ischemia.