— 生理適應 · HARD · MCQ —
護理師照護疑似肺栓塞的病人，下列哪項評估發現最令人擔憂？
A nurse is caring for a client with a suspected pulmonary embolism. Which assessment finding is most concerning?
- AUnilateral lower extremity edema單側下肢水腫
- BHypotension and tachycardia✓ 正解低血壓和心搏過速
- CChest pain upon deep inhalation深呼吸時胸痛
- DSudden onset of dyspnea突發性呼吸困難
— Explanation · 中文詳解 —
肺栓塞（Pulmonary embolism）若進展至低血壓（Hypotension）和心跳過速（Tachycardia），代表病人已進入阻塞性休克（Obstructive shock）。這意味著肺血管床被大面積阻塞，導致右心室負荷過重、心輸出量急劇下降。此時病人已無法維持重要器官的灌流，是臨床上最危險的徵象，需要立即進行積極的復甦與抗凝血治療。
Hypotension and tachycardia in a client with a suspected pulmonary embolism are the most concerning findings as they indicate obstructive shock and imminent cardiac arrest. This signifies that a large portion of the pulmonary vascular bed is blocked, severely reducing cardiac output and compromising perfusion to vital organs. Immediate intervention is required to stabilize hemodynamics.