— 降低風險 · MEDIUM · SATA —
護理師正在評估一位懷疑氣胸的病人。哪些臨床發現符合此診斷？（選所有適合的）
A nurse is assessing a client with a suspected pneumothorax. Which clinical findings are consistent with this condition? (Select all that apply.)
- ADiminished breath sounds on the affected side✓ 正解患側呼吸音減弱
- BTracheal deviation toward the affected side氣管向患側偏移
- CSudden onset of sharp pleuritic chest pain✓ 正解突發性尖銳胸膜性胸痛
- DHyperresonance on percussion of the affected side✓ 正解患側叩診呈過度回響音
- ETachycardia and tachypnea✓ 正解心搏過速與呼吸過速
— Explanation · 中文詳解 —
氣胸造成肋膜腔積氣，肺葉塌陷。臨床特徵包括患側呼吸音消失或減弱、扣診呈過度回響音（Hyperresonance）。病人在氣胸發生時常感到突發性刺痛，並伴隨心跳與呼吸速率代償性增加。選項 B 錯誤：氣管應偏移至健側（對側）。
Clinical findings consistent with pneumothorax include diminished breath sounds, hyperresonance on percussion, sudden pleuritic chest pain, and compensatory tachycardia and tachypnea due to hypoxia. Tracheal deviation would occur toward the unaffected side in a tension pneumothorax, not toward the affected side.
✦ 台美臨床差異
台美護理實務皆強調氣胸為醫療緊急事件，需優先準備胸管置入器材。