— 生理適應 · MEDIUM · MCQ —
一位急性氣喘發作的病人。哪項評估發現最令人擔憂？
A client is experiencing an acute asthma attack. Which assessment finding is most concerning?
- ATachycardia心跳過速
- BIncreased respiratory rate呼吸頻率增加
- CAbsence of wheezing✓ 正解無哮鳴音
- DInspiratory wheezing吸氣性哮鳴音
— Explanation · 中文詳解 —
氣喘發作時，鳴音（Wheezing）是氣流通過狹窄氣道的徵象。若鳴音突然消失，代表呼吸道已嚴重阻塞，通氣量極低（Silent chest），這是瀕臨呼吸衰竭的徵兆。這比單純的鳴音更令人擔憂，因為它代表病人已經疲憊到無法產生足夠的氣流來產生鳴音。護理師必須立刻處置，給予支氣管擴張劑、氧氣，並備妥插管準備。
The absence of wheezing, often called a 'silent chest,' is the most concerning finding as it indicates severe airway obstruction and critically low airflow. Unlike audible wheezing, which signifies some air movement, silence suggests the client is too fatigued to generate sufficient breath sounds, signaling impending respiratory failure.