— 生理適應 · MEDIUM · MCQ —
一位 55 歲患有高血壓的病人服用 lisinopril。哪項評估發現需要立即護理介入？
A 55-year-old client with a history of hypertension is prescribed lisinopril. Which assessment finding requires immediate nursing intervention?
- ABlood pressure reading of 130/85 mmHg血壓讀數為 130/85 mmHg
- BPersistent dry cough持續性乾咳
- CSwelling of the lips and tongue✓ 正解嘴唇和舌頭腫脹
- DMild headache輕微頭痛
— Explanation · 中文詳解 —
血管收縮素轉換酶抑制劑（ACEI）最嚴重的副作用為血管性水腫（angioedema），表現為唇舌腫脹，可能導致氣道阻塞。這是緊急醫療狀況。乾咳為常見但非緊急的副作用，血壓 130/85 為控制範圍，輕微頭痛亦非立即威脅生命的徵象。
Angioedema, manifested as swelling of the lips and tongue, is a severe and potentially life-threatening adverse reaction to ACE inhibitors like lisinopril that can lead to airway obstruction. While a dry cough is a common side effect, it is not an emergency. Other findings such as controlled blood pressure or mild headaches do not require immediate intervention compared to signs of compromised airway patency.
✦ 台美臨床差異
美台臨床皆視血管性水腫為首要警訊，但美國護理師常需更主動識別過敏反應並執行緊急 protocol。