— 生理適應 · HARD · SATA —
下列哪些評估結果提示病患可能發生心包填塞？（選所有適合的）
Which assessment findings should alert the nurse that a client is developing cardiac tamponade? (Select all that apply.)
- AMuffled heart sounds✓ 正解心音低沈
- BJugular vein distension✓ 正解頸靜脈怒張
- CHypotension✓ 正解低血壓
- DBradycardia心動過緩
- EPulsus paradoxus✓ 正解奇脈
— Explanation · 中文詳解 —
心包填塞的經典表現為貝克三徵象（Beck's Triad）：心音模糊、頸靜脈怒張、低血壓。此外，脈搏奇脈（Pulsus paradoxus，吸氣時收縮壓下降超過 10mmHg）也是極具診斷價值的臨床指標，與心包膜內壓上升限制心室填充有關。
Cardiac tamponade is characterized by Beck's triad: muffled heart sounds, jugular vein distension, and hypotension due to decreased cardiac output. Additionally, pulsus paradoxus, defined as a drop in systolic blood pressure greater than 10 mmHg during inspiration, is a classic diagnostic sign. Tachycardia, rather than bradycardia, is typically observed as the heart attempts to compensate for reduced stroke volume.
✦ 台美臨床差異
兩地均強調此為危急生命狀況，需立即備齊心包穿刺設備，護理師需協助準備相關程序。