— 降低風險 · HARD · MCQ —
一位病人因急性氣喘發作就診，護理師評估發現使用呼吸輔助肌且聽診呈現「靜默胸」。最準確的解讀為何？
A client presents with an acute asthma attack. The nurse assesses accessory muscle use and a silent chest. Which interpretation is most accurate?
- AThe client has developed pneumonia病人已發展出肺炎。
- BThe client's oxygen levels are normal病人的氧氣水平正常。
- CThe client's breathing is improving病人的呼吸狀況正在改善。
- DThe client is experiencing severe bronchoconstriction✓ 正解病人正經歷嚴重的支氣管痙攣。
— Explanation · 中文詳解 —
「靜默胸（Silent Chest）」在急性氣喘發作時是一個極度危險的臨床徵象。當病人呼吸音消失，代表氣道嚴重阻塞，氣流無法通過，這是呼吸衰竭的前兆。病人可能因過度疲勞而導致呼吸頻率下降，隨時可能呼吸停止（Respiratory Arrest）。護理師必須立刻呼叫醫師，準備急救設備（氣管插管、呼吸器），此時病人處於瀕死邊緣，絕非病情改善。
A silent chest during an acute asthma attack is a critical sign indicating severe bronchoconstriction and near-total airway obstruction. This ominous finding suggests that airflow is insufficient to produce breath sounds, signaling impending respiratory failure rather than improvement. Immediate medical intervention is required as the patient is at high risk for respiratory arrest.