— 生理適應 · MEDIUM · MCQ —
一位 55 歲高血壓病史病人主訴胸口突然出現撕裂感並放射至背部，護理師應首先懷疑何種狀況？
A 55-year-old client with a history of hypertension reports a sudden, severe "tearing" sensation in the chest radiating to the back. Which condition should the nurse suspect first?
- APulmonary embolism肺栓塞
- BMyocardial infarction心肌梗塞
- CAortic dissection✓ 正解主動脈剝離
- DEsophageal rupture食道破裂
— Explanation · 中文詳解 —
主動脈剝離（aortic dissection）是一種血管急症，其典型臨床表現為突發性、撕裂性（tearing/ripping）胸痛，且疼痛常放射至背部肩胛骨間。護理師需區分其與心肌梗塞的壓迫感不同。臨床護理優先順序為維持血流動力學穩定，立即控制收縮壓與心跳，以降低對主動脈壁的剪力（shearing force），防止剝離範圍擴大。
The sudden, tearing chest pain radiating to the back is the hallmark symptom of aortic dissection, a vascular emergency. The nurse must prioritize stabilizing hemodynamics by controlling blood pressure and heart rate to reduce shear stress on the aortic wall.