一位 55 歲高血壓病史病人主訴胸口出現撕裂感並放射至背部。下列何項評估發現需要護理師立即處置？
A 55-year-old client with a history of hypertension reports a sudden, severe "tearing" sensation in the chest radiating to the back. Which assessment finding requires immediate nursing intervention?
- AHeart rate of 88 beats per minute心率88次/分
- BOxygen saturation of 96% on room air室空氣下血氧飽和度96%
- CBlood pressure difference of 20 mmHg between arms✓ 正解雙臂血壓相差20 mmHg
- DResting respiratory rate of 18 breaths per minute靜止呼吸速率18次/分
撕裂感胸痛放射至背部是典型主動脈剝離（Aortic Dissection）的臨床症狀，屬於急診中的心血管急症。兩側手臂血壓差距顯著（通常大於 20 mmHg）是因為剝離範圍壓迫到了血管分枝，導致血流灌流不均。當護理師發現此體徵時，必須意識到這代表血管壁結構已嚴重損害，隨時有破裂風險。護理師應立即將病人安置於靜態環境，減少心肌負荷，通知醫療團隊準備緊急影像檢查（如 CT Angiography），並可能需要進行緊急手術治療。此類病人最忌諱血壓波動，維持穩定的循環狀態是黃金關鍵，任何延遲都可能導致死亡率飆升。這題強調了對症狀背後病理機制的警覺性，這是護理師在面對急性心血管症狀時的判斷核心。
A significant blood pressure difference between arms suggests aortic dissection, a life-threatening emergency where the aortic wall tears. This finding indicates compromised blood flow due to vessel compression and requires immediate intervention to stabilize the client and prepare for urgent diagnostic imaging or surgery.
美國護理師在急診對於此類高危病人有較高的自主權（如直接啟動急性胸痛 protocol），台灣護理師通常在醫師評估過後才執行更積極的藥物調整，但兩者對於『兩側血壓差異』的警覺教育一致。