— 生理適應 · MEDIUM · MCQ —
懷疑腸阻塞的病人。護理師預期在阻塞部位上方會聽到哪種腸鳴音？
A client is admitted with a suspected bowel obstruction. Which bowel sound assessment should the nurse expect to find above the obstruction?
- ANormal gurgling sounds正常咕嚕聲
- BAbsent bowel sounds腸鳴音消失
- CHypoactive bowel sounds低活動性腸鳴音
- DHigh-pitched, tinkling sounds✓ 正解高頻、叮噹聲
— Explanation · 中文詳解 —
腸阻塞 (bowel obstruction) 是指腸道內容物通過受阻。在腸阻塞的早期階段，阻塞部位上方的腸道會嘗試克服阻力，導致腸蠕動 (peristalsis) 顯著增加。這種劇烈的腸道收縮會產生獨特的聽診聲音。隨著腸阻塞的進展，腸道會變得疲憊，蠕動可能減弱，最終可能完全停止，導致阻塞部位上方的腸鳴音變弱甚至消失。因此，護理師需了解腸阻塞不同階段的腸鳴音變化，以提供準確的評估。
Above a suspected bowel obstruction, the nurse should expect high-pitched, tinkling bowel sounds caused by the intestines attempting to push contents past the blockage. This hyperactive pattern contrasts with hypoactive or absent sounds, which may occur below the obstruction or in later stages of ileus.