— 生理適應 · MEDIUM · MCQ —
一名急性胰臟炎病人表現出嚴重腹痛。下列哪項評估發現需要立即護理介入？
A client with acute pancreatitis presents with severe abdominal pain. Which assessment finding requires immediate nursing intervention?
- ABowel sounds hypoactive in all quadrants各象限腸鳴音減弱
- BSerum amylase level of 800 U/L血清澱粉酶濃度 800 U/L
- CReports of 8/10 pain intensity自述疼痛強度為 8/10
- DBlood pressure of 90/60 mmHg✓ 正解血壓 90/60 mmHg
— Explanation · 中文詳解 —
急性胰臟炎常見併發症為低血容性休克，因發炎導致血管通透性增加及液體流失至第三空間。低血壓顯示病人處於血流動力學不穩狀態，需優先進行液體復甦。其餘選項雖是胰臟炎的典型臨床表現，但在緊急度上低於休克徵象。
A common complication of acute pancreatitis is hypovolemic shock, caused by increased vascular permeability from inflammation and fluid shifts into the third space. Hypotension indicates that the client is hemodynamically unstable, requiring priority fluid resuscitation. The other options, although typical clinical manifestations of pancreatitis, are less urgent than signs of shock.
✦ 台美臨床差異
美國護理師常依據給定指引直接啟動輸液；台灣則通常在醫師確認後給予 Bolus。