— 降低風險 · HARD · SATA —
護理師評估一位疑似氣胸的病人。應預期見到哪些臨床表徵？（選所有適合的）
A nurse is performing an assessment on a client with a suspected pneumothorax. Which clinical findings should the nurse expect? (Select all that apply.)
- ADiminished or absent breath sounds on the affected side✓ 正解患側呼吸音減弱或消失
- BTracheal deviation toward the unaffected side✓ 正解氣管向未受影響側偏移
- CHyper-resonance on percussion✓ 正解叩診呈過度共鳴音
- DSudden onset of sharp chest pain✓ 正解突發性尖銳胸痛
- EIncreased chest wall expansion on the affected side患側胸壁擴張增加
— Explanation · 中文詳解 —
氣胸病人因胸膜腔內積氣，導致肺部塌陷。臨床表徵包括患側呼吸音消失、叩診呈現過度共鳴（Hyper-resonance）。若演變為張力性氣胸，壓力會將氣管推向健側。病人常有突發性尖銳胸痛。E 選項錯誤，氣胸患側胸壁擴張反而會減少，不會增加。
Appropriate interventions include increasing oral fluids to prevent dehydration, monitoring electrolytes, providing a low-fiber bland diet to reduce bowel activity, and performing perineal care after each bowel movement to protect skin integrity. Spicy foods should be avoided as they can irritate the gastrointestinal tract.
✦ 台美臨床差異
台美對氣胸的處置皆強調立即胸管置入，美國護理師有時需協助在急診室進行針頭減壓。