— 生理適應 · HARD · SATA —
一位懷疑張力性氣胸的病人。應預期哪些臨床發現？（選所有適合的）
A nurse is assessing a client with a suspected tension pneumothorax. Which clinical findings are expected? (Select all that apply.)
- ATracheal deviation to the unaffected side✓ 正解氣管向未受損側偏移
- BHypotension✓ 正解低血壓
- CTachycardia✓ 正解心搏過速
- DIncreased breath sounds on the affected side受損側呼吸音增強
- EDistended neck veins✓ 正解頸靜脈怒張
— Explanation · 中文詳解 —
張力性氣胸會因胸腔內壓力極高，將氣管推向健側，並壓迫大血管減少回心血量，導致低血壓、心跳加速與頸靜脈怒張（Distended neck veins）。受損側肺部因萎陷，聽診呼吸音會消失（Absent），絕非增加。這屬於緊急手術干預的狀況。
Tension pneumothorax causes high intrathoracic pressure that shifts the mediastinum, pushing the trachea toward the unaffected side and impairing venous return. This results in hypotension, tachycardia, and distended neck veins, while breath sounds on the affected side are absent due to lung collapse rather than increased.
✦ 台美臨床差異
兩地皆強調張力性氣胸需「立即減壓」（減壓針或胸管），護理師應立即通知醫師或執行緊急 Protocol。