— 生理適應 · MEDIUM · MCQ —
一位 55 歲高血壓病史病人主訴嚴重胸骨下疼痛。護理師應優先處理下列哪項發現？
A 55-year-old client with a history of hypertension reports severe substernal chest pain. Which finding requires the most immediate intervention by the nurse?
- AHeart rate 105 beats per minute心率每分鐘 105 次
- BPeripheral edema 1+周邊水腫 1+
- CST-segment elevation on the cardiac monitor✓ 正解心臟監測器上出現 ST 段上升
- DBlood pressure 160/95 mmHg血壓 160/95 mmHg
— Explanation · 中文詳解 —
對於嚴重胸痛的病人，護理師應優先執行 ABC（Airway, Breathing, Circulation）原則，並評估是否為急性冠心症（ACS）。心電圖（ECG）呈現 ST 波段上升（STEMI）代表心肌已發生急性損傷，若不立即處理，將導致心肌壞死與致命性心律不整。相較於血壓高或心跳快，ST 波段改變直接指向心臟肌肉的急性危機，具有最高的臨床急迫性。
ST-segment elevation on a cardiac monitor indicates acute myocardial injury, such as a STEMI, which requires immediate reperfusion therapy to prevent necrosis. While tachycardia and hypertension are present, the ECG changes represent the most urgent clinical crisis requiring immediate intervention.