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生理適應 · MEDIUM · MCQ

氣喘病史的病人出現何種評估發現時,需立即採取干預措施?

Which assessment finding in a client with a history of asthma requires immediate intervention?

  • ASilent chest✓ 正解
    無呼吸音(沉默胸)
  • BExpiratory wheezing
    呼氣性喘鳴
  • CRespiratory rate of 22 breaths/min
    呼吸頻率為每分鐘 22 次
  • DProductive cough
    有痰咳嗽
Explanation · 中文詳解

氣喘急性發作時,聽診呼吸音消失(Silent chest)代表氣道極度阻塞,空氣無法進入肺部進行交換,這是即將發生呼吸衰竭的危急徵象。相比之下,喘鳴聲(Wheezing)仍代表有氣流進出,雖然嚴重但危險程度低於完全阻塞。

A silent chest indicates severe airway obstruction with minimal to no air movement, signaling imminent respiratory failure. This finding requires immediate intervention as it represents a critical deterioration compared to wheezing, which still indicates some airflow.

✦ 台美臨床差異

在美國護理考試中,Silent chest 是經典的考題陷阱;台灣臨床亦將此列為呼叫急救小組的徵象。

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