— 降低風險 · HARD · SATA —
護理師評估一位懷疑氣胸的病人，應預期發現哪些臨床表現？（選所有適合的）
A nurse is assessing a client with a suspected pneumothorax. Which clinical findings should the nurse expect to identify? (Select all that apply.)
- ADiminished breath sounds on the affected side✓ 正解患側呼吸音減弱
- BTracheal deviation toward the affected side氣管向患側偏移
- CSudden, sharp chest pain✓ 正解突然且尖銳的胸痛
- DHyper-resonance on percussion of the affected side✓ 正解患側叩診呈過清音
- ETachycardia and tachypnea✓ 正解心搏過速和呼吸過速
— Explanation · 中文詳解 —
氣胸常見表現包括患側呼吸音減弱（因為氣體阻隔）、突發性尖銳胸痛、叩診呈過度共鳴（Hyper-resonance，因充滿氣體）。病人通常因缺氧而出現代償性的心跳過速與呼吸急促。氣管偏移（Tracheal deviation）通常只發生在張力性氣胸時，且應偏向「健側」而非患側，故選項 B 錯誤。
Expected findings for a pneumothorax include diminished breath sounds on the affected side, sudden sharp chest pain, hyper-resonance on percussion, and compensatory tachycardia and tachypnea due to hypoxia. Tracheal deviation typically occurs only in tension pneumothorax and shifts toward the unaffected side, making deviation toward the affected side incorrect.
✦ 台美臨床差異
台美皆強調張力性氣胸為急症，需立即準備插管減壓，但美國護理師更常參與院前或急診的第一線評估。