— 生理適應 · HARD · SATA —
哪種評估發現應警示護理師，肺炎病人可能出現呼吸性酸中毒？（選所有適合的）
Which assessment findings should alert the nurse to the development of respiratory acidosis in a client with pneumonia? (Select all that apply.)
- AConfusion and lethargy✓ 正解意識混亂和嗜睡
- BHypoventilation✓ 正解換氣不足
- CTachycardia✓ 正解心搏過速
- DIncreased arterial pH動脈pH值升高
- EElevated partial pressure of carbon dioxide (PaCO2)✓ 正解二氧化碳分壓（PaCO2）升高
— Explanation · 中文詳解 —
呼吸性酸中毒源於肺部換氣不足，導致二氧化碳蓄積（PaCO2上升）。低換氣（Hypoventilation）會引起高碳酸血症，進而使 pH 值下降（酸血症）。臨床表現包括中樞神經功能抑制（嗜睡、混亂）以及心血管代償反應（心跳加速）。選項 D 錯誤，因為酸中毒 pH 值應為降低而非升高。
Respiratory acidosis results from hypoventilation and carbon dioxide retention, leading to elevated PaCO2 and decreased pH. Clinical signs include confusion and lethargy due to cerebral effects, along with tachycardia as a compensatory mechanism, distinguishing it from alkalosis where pH would be increased.
✦ 台美臨床差異
兩地對酸鹼平衡的生理監測無顯著差異，均依賴 ABG 數值進行臨床判斷。