— 生理適應 · MEDIUM · MCQ —
護理師正在評估一位有心臟衰竭且出現疲勞與呼吸短促的病人。哪項額外發現提示肺部鬱血惡化？
A nurse is assessing a client with heart failure who is experiencing fatigue and shortness of breath. Which additional finding suggests worsening pulmonary congestion?
- AWeight loss體重減輕
- BCrackles in the lung bases✓ 正解肺底囉音
- CIncreased appetite食慾增加
- DDry cough乾咳
— Explanation · 中文詳解 —
肺部鬱血是左心衰竭的典型表現，即體液回流至肺部循環。當液體積聚在肺泡時，會產生囉音（crackles）。乾咳有時也是鬱血的表現，但囉音是更直接的聽診發現。食慾增加、體重減輕通常與右心衰竭（食慾不振、噁心）相反。
Crackles in the lung bases are a definitive sign of worsening pulmonary congestion and fluid accumulation in the alveoli, characteristic of left-sided heart failure. While other symptoms like weight loss or dry cough may occur, crackles directly indicate the presence of pulmonary edema.
✦ 台美臨床差異
美國的護理師在評估心衰竭病人時，會強調聽診與影像學檢查的結合；台灣的照護也包含聽診，但病人對症狀變化的主訴是重要依據。