— 生理適應 · HARD · MCQ —
護理師照顧一位頸椎 C4 損傷病人。下列哪項評估結果需要立即採取護理行動？
A nurse is monitoring a client with a cervical spinal cord injury at the level of C4. Which assessment finding requires immediate nursing intervention?
- ARespiratory rate of 10 breaths/min with shallow depth✓ 正解呼吸頻率為每分鐘10次且呼吸淺
- BReported anxiety regarding prognosis對預後表示焦慮
- CBlood pressure of 160/90 mmHg血壓為160/90 mmHg
- DHeart rate of 55 beats/min心率為每分鐘55次
— Explanation · 中文詳解 —
C4 損傷會影響膈神經控制，導致呼吸功能受損。呼吸頻率 10 次且深度淺，代表換氣不足，隨時會導致呼吸停止。自主神經反射異常（Autonomic Dysreflexia）常伴隨高血壓，但呼吸衰竭是立即致命的 ABC 問題。心跳過緩則是常見的脊髓休克表現，需監測但優先級低於呼吸。
A respiratory rate of 10 breaths/min with shallow depth indicates hypoventilation and potential respiratory failure, requiring immediate intervention. Since a C4 spinal cord injury compromises the phrenic nerve and diaphragm function, maintaining adequate oxygenation is the highest priority over other findings.
✦ 台美臨床差異
美台皆強調脊髓損傷病人的呼吸監測，但在台灣對於高位頸損病人，預防性氣切決策通常較為積極。