— 生理適應 · HARD · MCQ —
一位氣喘急性發作的病患，下列哪項評估發現需要立即處理？
A nurse is caring for a client experiencing an acute asthma attack. Which assessment finding requires immediate intervention?
- ASilent chest upon auscultation✓ 正解聽診時胸部無呼吸音
- BHeart rate of 105 beats per minute心跳速率每分鐘 105 次
- CPresence of expiratory wheezing存在呼氣性哮鳴音
- DUse of accessory respiratory muscles使用輔助呼吸肌肉
— Explanation · 中文詳解 —
氣喘發作時，聽診無呼吸音（Silent chest）代表氣流完全阻滯，意味著氣道嚴重狹窄或已進入呼吸衰竭，是最危急的徵象。其他選項（喘鳴、輔助肌使用、心搏過速）雖為發作表現，但無呼吸音表示通氣即將停止。
A silent chest upon auscultation during an acute asthma attack is a critical finding indicating severely diminished airflow and impending respiratory failure. While tachycardia, wheezing, and accessory muscle use are common signs of distress, the absence of breath sounds suggests that air movement is critically compromised and requires immediate intervention.
✦ 台美臨床差異
美國強調優先處理聽診發現的無呼吸音；台灣臨床亦重視，但對於氣喘處置的層級評估更加謹慎。