# 一位周邊水腫惡化且頸靜脈怒張的個案，有吹風樣的全收縮期心雜音，且在吸氣時變大聲。點擊護理師應專注聽診以進一步評估此型態的部位。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=581203&lang=zh-tw  
> language: zh-TW  
> subject: Physiological Adaptation  
> category: PA

## 題目

一位周邊水腫惡化且頸靜脈怒張的個案，有吹風樣的全收縮期心雜音，且在吸氣時變大聲。點擊護理師應專注聽診以進一步評估此型態的部位。

![](https://mymerci.kr/data/nclex/hotspot/regen_20260908_2350/HSR540.svg)

## 解析

D 是胸骨左下緣區域，為三尖瓣逆流心雜音的典型聽診焦點。

## 深入解析

快速解答
D. D 是胸骨左下緣區域，為三尖瓣逆流心雜音的典型聽診焦點。
為何這是最佳選擇
結合全收縮期特質、吸氣增強及全身靜脈充血。這些線索支持聚焦評估三尖瓣逆流，而非僅因心雜音為收縮期就選擇心尖部位。需進一步診斷評估以確認病因。
臨床情境
這些觀察為虛構的教學資料。請應用所述情境；所選特徵本身不能取代完整的床邊評估。
記憶訣竅
在選擇聽診部位前，應同時運用時間點、呼吸反應及相關發現。
決策規則
在選擇聽診部位前，應同時運用時間點、呼吸反應及相關發現。
為何其他部位不合適
A 和 B 是胸骨上緣聽診區，C 位於左緣較高處。E 是心尖二尖瓣區；二尖瓣逆流心雜音可為全收縮期，但吸氣增強及靜脈充血在此情況下傾向選擇 D。
**資料來源**
- 三尖瓣逆流可在胸骨中下左緣產生全收縮期心雜音，且吸氣時增強。

## 重要概念

- **Respiratory change distinguishes a right-sided regurgitant murmur** — 在選擇聽診部位前，應同時運用時間點、呼吸反應及相關發現。
- **Comparison with context** — E 對另一種全收縮期逆流心雜音而言是合理的，但呼吸反應可加以區分。

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