— 生理適應 · HARD · SATA —
護理師照顧一位懷疑肺栓塞的病人。應監測哪些臨床表徵？（選所有適合的）
A nurse is caring for a client with a suspected pulmonary embolism. Which clinical manifestation should the nurse monitor for? (Select all that apply.)
- ASudden onset of dyspnea✓ 正解突發性呼吸困難
- BPleuritic chest pain✓ 正解胸膜炎性胸痛
- CTachycardia✓ 正解心搏過速
- DBradypnea呼吸過慢
- EHemoptysis✓ 正解咳血
— Explanation · 中文詳解 —
肺栓塞（Pulmonary Embolism, PE）是指血栓阻塞肺動脈，導致氣體交換障礙與血流動力學異常。診斷關鍵在於評估突發性呼吸窘迫及相關心肺症狀。護理師需透過觀察呼吸型態、胸痛性質及生命徵象來判斷。臨床思路應優先考慮『呼吸循環不穩定』，PE 會造成換氣灌流不匹配（V/Q mismatch），導致低血氧與代償性心搏過速。Hemoptysis 是因肺梗塞造成的出血表現，也是重要警訊。
Pulmonary embolism typically presents with sudden dyspnea, pleuritic chest pain, tachycardia, and hemoptysis due to impaired gas exchange and potential pulmonary infarction. Bradypnea is not expected; instead, tachypnea occurs as a compensatory mechanism for hypoxia and decreased cardiac output.