— 生理適應 · HARD · MCQ —
護理師照護一位燒燙傷病人，哪項發現需要立即護理介入？
A nurse is caring for a client who has sustained a burn injury. Which assessment finding requires immediate nursing intervention?
- ATachycardia心跳過速
- BHoarseness and brassy cough✓ 正解聲音嘶啞與金屬音咳嗽
- CBlistering on the arm手臂出現水泡
- DPain level of 8/10疼痛程度 8/10
— Explanation · 中文詳解 —
燒燙傷病人若出現聲音沙啞（Hoarseness）或金屬音咳嗽，代表呼吸道可能已經遭到吸入性損傷（Inhalation injury），呼吸道腫脹會隨時間迅速惡化，這被視為呼吸道的危急徵象，需優先評估氣道與考慮插管。
Hoarseness and a brassy cough indicate potential airway edema and inhalation injury, which can rapidly progress to airway obstruction. This finding requires immediate assessment and intervention to secure the airway, as it poses a greater threat to life than tachycardia, blistering, or pain alone.
✦ 台美臨床差異
美國 Burn Unit 護理師對於吸入性損傷的警覺性極高，台灣護理師在接獲燒燙傷病人時同樣需將此列為首要評估指標。