— 生理適應 · HARD · MCQ —
一位 55 歲高血壓病史病人主訴突發性撕裂狀胸痛並放射至背部。護理師最應關注下列哪項評估結果？
A 55-year-old client with a history of hypertension reports a sudden onset of severe tearing chest pain radiating to the back. Which assessment finding is most concerning to the nurse?
- ABlood pressure difference of 20 mmHg between arms✓ 正解雙臂血壓相差 20 mmHg
- BOxygen saturation of 94% on room air在室溫下氧飽和度為 94%
- CHeart rate of 98 beats per minute心率为每分钟 98 次
- DRespiration rate of 22 breaths per minute呼吸频率为每分钟 22 次
— Explanation · 中文詳解 —
撕裂狀胸痛放射至背部為典型主動脈剝離（Aortic dissection）症狀。雙側手臂血壓不對稱（>20 mmHg）是因為剝離影響主動脈弓及其分支的血流量，這是診斷該病極具價值的臨床發現。護理師必須對此徵兆保持極高警覺，立即通知醫師並準備緊急電腦斷層與手術評估，否則主動脈管壁完整性受損，死亡風險極高。
A blood pressure difference of more than 20 mmHg between arms is a critical sign of aortic dissection, indicating involvement of the subclavian arteries. This finding requires immediate notification of the provider and preparation for emergency diagnostic imaging and surgical evaluation due to the high risk of mortality.