— 降低風險 · MEDIUM · MCQ —
護理師為一位重度慢性阻塞性肺病（COPD）病人進行身體評估。哪些跡象需要立即行動？
A nurse is performing a physical assessment on a client with severe COPD. Which signs require immediate action?
- AChronic cough with sputum伴有痰液的慢性咳嗽
- BIncreased dyspnea and confusion✓ 正解呼吸困難加重伴隨意識混亂
- CClubbed fingers手指杵狀變
- DBarrel chest桶狀胸
— Explanation · 中文詳解 —
慢性阻塞性肺病（COPD）的臨床評估重點在於區分「慢性代償表現」與「急性失代償跡象」。杵狀指、桶狀胸及慢性咳嗽屬於長期肺部氣流受阻的適應性改變，屬穩定狀態。然而，呼吸困難加劇合併意識混亂，強烈暗示了二氧化碳滯留（Hypercapnia）導致的二氧化碳麻醉或嚴重的低血氧（Hypoxemia），這是致命的急性呼吸衰竭徵兆，屬於 ABC 原則中呼吸（Breathing）層級的緊急狀態，需護理師採取立即的呼吸支持介入。
While chronic cough, clubbing, and barrel chest are expected findings in stable COPD, increased dyspnea accompanied by confusion signals acute decompensation. This combination suggests hypercapnia leading to CO2 narcosis or severe hypoxemia, which are life-threatening respiratory emergencies requiring immediate intervention.