— 生理適應 · MEDIUM · MCQ —
一位慢性阻塞性肺病 (COPD) 病人因呼吸困難加劇和喘鳴入院。護理師評估病人呼吸狀態。哪項發現需要立即介入？
A client with chronic obstructive pulmonary disease (COPD) is admitted with increased shortness of breath and wheezing. The nurse assesses the client's respiratory status. Which finding requires immediate intervention?
- AInability to speak more than a few words at a time✓ 正解一次無法說超過幾個字
- BSpO2 90% on 2 L oxygen在 2 L 氧氣下 SpO2 為 90%
- CDistant breath sounds呼吸音遙遠
- DUse of accessory muscles使用呼吸輔助肌
— Explanation · 中文詳解 —
對於 COPD 病人，呼吸評估的重點在於判斷呼吸衰竭的徵象。當病人無法完整講出一個句子（Inability to speak in full sentences）時，這顯示病人的呼吸儲備已極度耗竭，必須動用所有呼吸肌來維持換氣，甚至無法分出餘力來發聲。這是呼吸窘迫（Respiratory Distress）惡化至呼吸衰竭的危險警訊，比起血氧飽和度或聽診結果，這種功能性的呼吸能力喪失需要護理師最優先處理。
An inability to speak more than a few words indicates severe respiratory distress and impending respiratory failure, requiring immediate intervention. While other findings like distant breath sounds or accessory muscle use are common in COPD exacerbations, speech impairment signals critical airway compromise.