— 降低風險 · MEDIUM · MCQ —
一位有心衰竭病史的病人自述呼吸困難加重，哪項評估發現最令人擔心？
A nurse is assessing a client with a history of heart failure who reports increased shortness of breath. Which assessment finding is most concerning?
- ABilateral crackles at the base of the lungs✓ 正解雙側肺底囉音
- BWeight gain of 1 pound in one week一週內體重增加1磅
- CBlood pressure of 120/80 mmHg血壓120/80 mmHg
- DPeripheral edema in ankles腳踝周邊水腫
— Explanation · 中文詳解 —
肺部基底出現雙側囉音（Crackles）代表液體已滲入肺泡，這顯示心衰竭已導致肺水腫，屬嚴重臨床徵兆。下肢水腫雖是心衰竭特徵，但屬於慢性現象。一週增加 1 磅通常在體重波動範圍，120/80 為正常血壓。
Bilateral crackles at the lung bases indicate fluid accumulation in the alveoli, signaling acute pulmonary edema, which is a medical emergency in heart failure. Although peripheral edema and weight gain are signs of fluid retention, pulmonary crackles represent a more immediate threat to respiratory status.
✦ 台美臨床差異
台灣醫護人員常優先詢問端坐呼吸或陣發性夜間呼吸困難，評估肺水腫症狀時兩地具高度一致性。