— 降低風險 · MEDIUM · MCQ —
護理師照護一位急性氣喘發作的病人，哪項評估發現是呼吸衰竭的前兆？
A nurse is caring for a client who is experiencing an acute asthma attack. Which assessment finding should the nurse identify as a sign of impending respiratory failure?
- ASilent chest✓ 正解寂靜胸
- BInspiratory wheezing吸氣性哮鳴音
- CUse of accessory muscles使用呼吸輔助肌肉
- DTachypnea呼吸過速
— Explanation · 中文詳解 —
在急性氣喘發作中，護理師需密切監測呼吸狀態。若病人出現「寂靜胸（Silent chest）」，即聽診時原本的喘鳴音消失，這代表氣道阻塞已達到極度嚴重的程度，氣流極度受限，病人無法維持足夠的通氣量，隨時可能發生呼吸停止（Respiratory arrest）。這是呼吸衰竭的前兆，必須立即給予積極的醫療介入（如支氣管擴張劑、類固醇、甚至輔助通氣）。
A silent chest, characterized by the absence of wheezing upon auscultation, indicates severe airway obstruction and critically reduced airflow. This finding suggests that the client is too fatigued to generate sufficient air movement and is a warning sign of impending respiratory failure requiring immediate intervention.