— 生理適應 · HARD · MCQ —
一位病人因氣喘發作就診。哪項評估結果最令護理師擔憂？
A client presents with an asthma attack. Which assessment finding is most concerning to the nurse?
- ASilent chest✓ 正解寂靜胸
- BExpiratory wheezing呼氣哮鳴音
- CUse of accessory muscles使用輔助呼吸肌
- DTachypnea呼吸急促
— Explanation · 中文詳解 —
在氣喘發作時，哮鳴音（Wheezing）的存在代表尚有空氣通過狹窄氣道。一旦出現「寂靜胸（Silent chest）」，代表氣道阻塞已非常嚴重，氣體交換幾乎停滯，病人面臨呼吸衰竭的極高風險，是氣喘發作中最危險的徵象。
A silent chest indicates severe airflow obstruction where insufficient air movement prevents wheezing sounds, signaling impending respiratory failure. This is the most critical finding because it suggests gas exchange has nearly ceased, unlike wheezing which confirms some air passage.
✦ 台美臨床差異
台美兩地護理師對「寂靜胸」的判讀皆屬進階評估範疇，皆需立即啟動緊急醫療應變程序。