— 生理適應 · MEDIUM · SATA —
硬化症個案出現哪些評估結果代表有併發症，需護理師介入？（選所有適合的）
Which assessment findings in a client with cirrhosis indicate potential complications that require nursing action? (Select all that apply.)
- AAsterixis (hand flapping tremor)✓ 正解撲翼樣震顫 (手拍樣震顫)
- BMelena (black, tarry stools)✓ 正解黑便 (黑色焦油樣糞便)
- CJaundice黃疸
- DMental status changes✓ 正解意識狀態改變
- EAscites腹水
— Explanation · 中文詳解 —
肝硬化常見危險併發症包括：肝性腦病變（表現為撲翼樣震顫 Asterixis 及意識改變）及食道靜脈曲張出血（表現為黑便）。黃疸與腹水雖為硬化症的臨床徵狀，但屬於長期病程的表徵，而撲翼樣震顫與黑便顯示急性危機，需立即醫療處置。
Dangerous complications commonly associated with cirrhosis include hepatic encephalopathy (manifested as asterixis and altered mental status) and bleeding esophageal varices (manifested as melena). Although jaundice and ascites are clinical features of cirrhosis, they reflect the long-term disease course, whereas asterixis and melena indicate acute crisis and require immediate medical intervention.
✦ 台美臨床差異
台灣臨床對於食道靜脈曲張病人通常會安排早期內視鏡結紮，而美國護理師常負擔篩檢與病人分流評估。