— 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。