— 降低風險 · HARD · SATA —
哪些評估發現應提示護理師注意一位全層胸部燒傷病人的潛在併發症？（選所有適合的）
Which assessment findings should alert the nurse to potential complication in a client with a full-thickness chest burn? (Select all that apply.)
- ADecreased chest wall excursion✓ 正解胸壁活動度減弱
- BInability to palpate distal pulses in the arms無法觸摸到手臂的遠端脈搏
- CPresence of a wheezing sound on auscultation✓ 正解聽診時出現哮鳴音
- DDeep, rapid respirations with clear breath sounds深呼吸且呼吸急促，但呼吸音清晰
- ETight, leathery eschar formation✓ 正解緊繃、皮革樣的焦痂形成
— Explanation · 中文詳解 —
全層胸部燒傷（Full-thickness chest burn）會形成僵硬的焦痂（Eschar），限制胸廓擴張，導致換氣受限（Decreased chest wall excursion）。此外，胸部燒傷常伴隨吸入性損傷，出現喘鳴音（Wheezing）。若焦痂過緊產生環狀收縮，會進一步壓迫呼吸，需緊急進行焦痂切開術（Escharotomy）。護理師應密切監測這些併發症，確保病人呼吸功能維持穩定。
Full-thickness chest burns form tight, leathery eschar that restricts chest wall excursion, potentially leading to respiratory failure. Nurses must monitor for decreased chest movement and wheezing, which may indicate concurrent inhalation injury or airway obstruction. These complications require immediate intervention, such as escharotomy, to restore adequate ventilation.