— 生理適應 · HARD · SATA —
護理師照顧急性氣喘發作病人，下列何種發現需要立即介入？（選所有適合的）
A nurse is caring for a client experiencing an acute asthma attack. Which assessment findings require immediate intervention? (Select all that apply.)
- ASilent chest upon auscultation✓ 正解聽診時胸部無呼吸音
- BInspiratory wheezing吸氣性哮鳴音
- CTachypnea呼吸急促
- DUse of accessory muscles✓ 正解使用輔助呼吸肌
- EBradycardia✓ 正解心跳過緩
— Explanation · 中文詳解 —
氣喘發作時，安靜的胸腔代表氣道已嚴重阻塞、缺乏氣流，而非改善；使用呼吸輔助肌代表呼吸衰竭瀕臨；心搏過慢在呼吸困難病人身上是即將發生心臟驟停的警訊。吸氣性哮鳴與呼吸急促雖為病徵，但在氣喘發作初期常見，相較於上述選項較不屬於極端危急的生命徵象失控。
Unrelieved pain despite medication and paresthesia are early signs of compartment syndrome, a surgical emergency requiring immediate notification of the healthcare provider. Elevation above the heart is contraindicated as it reduces arterial perfusion, while delaying intervention can lead to irreversible tissue necrosis.
✦ 台美臨床差異
美國護理師在面對 silence chest 時通常有權直接啟動 Rapid Response Team；台灣護理師多需醫師判定後才啟動急救團隊。