— 生理適應 · MEDIUM · SATA —
護理師照護疑似氣胸的病人，應預期出現哪些臨床表徵？（選所有適合的）
A nurse is caring for a client with a suspected pneumothorax. Which clinical manifestations should the nurse expect? (Select all that apply.)
- AAbsent or diminished breath sounds on the affected side✓ 正解患側呼吸音消失或減弱
- BTracheal deviation toward the unaffected side✓ 正解氣管向未受影響側偏移
- CHyperresonance on percussion✓ 正解叩診呈過清音
- DSudden onset of sharp chest pain✓ 正解突發性銳利胸痛
- EBradycardia and hypertension心搏過緩與高血壓
— Explanation · 中文詳解 —
氣胸病人因胸膜腔內積氣，導致肺部塌陷，進而出現患側呼吸音消失、叩診呈現過度共鳴音。若發展為張力性氣胸，壓力將推擠縱膈腔，使氣管偏移至健側。突發性尖銳胸痛為典型症狀。E 選項錯誤，氣胸病人通常會出現心搏過速（代償性）而非心搏過緩。
Expected manifestations include absent breath sounds, tracheal deviation, hyperresonance, and sudden sharp chest pain due to air accumulation and lung collapse. Bradycardia is incorrect because pneumothorax typically causes tachycardia as a compensatory response to hypoxemia.
✦ 台美臨床差異
台灣急診常備有針頭穿刺減壓包，護理師需熟悉張力性氣胸的紅旗徵象，以便隨時協助醫師。