— 生理適應 · MEDIUM · MCQ —
一位病人因疑似肺栓塞入院，下列哪項評估發現最符合此診斷？
A client is admitted with a suspected pulmonary embolism. Which assessment finding is most consistent with this diagnosis?
- ASudden onset of dyspnea and pleuritic chest pain✓ 正解突發性呼吸困難與胸膜性胸痛
- BStridor and wheezing on inspiration吸氣時的喘鳴與哮鳴
- CBilateral lower extremity edema雙側下肢水腫
- DProductive cough with rust-colored sputum伴有鐵鏽色痰的產痰性咳嗽
— Explanation · 中文詳解 —
肺栓塞（Pulmonary embolism）的典型症狀為突然發作的呼吸困難與胸痛。栓子阻塞肺部血管，導致肺部灌流不足，氣體交換受阻，病人會出現低血氧。肋膜性胸痛（Pleuritic chest pain）是因為肺梗塞刺激壁層肋膜所致。護理師需對此類突發性呼吸症狀保持高度警戒，因為 PE 是危及生命的急症。
Sudden onset dyspnea and pleuritic chest pain are hallmark signs of pulmonary embolism due to vascular obstruction and potential lung infarction. Stridor suggests upper airway issues, while rust-colored sputum indicates pneumonia. Although lower extremity edema may suggest deep vein thrombosis, it does not confirm pulmonary involvement.