— 生理適應 · MEDIUM · MCQ —
一位病人正經歷急性胰臟炎。何項評估發現需要立即的護理干預？
A client is experiencing acute pancreatitis. Which assessment finding requires immediate nursing intervention?
- ANausea and vomiting噁心和嘔吐
- BBlood pressure of 90/50 mmHg✓ 正解血壓 90/50 mmHg
- CAbdominal pain relieved by lying still靜止時減輕的腹痛
- DTemperature of 101.5°F (38.6°C)體溫 101.5°F (38.6°C)
— Explanation · 中文詳解 —
急性胰臟炎可能導致大量液體從血管滲入胰臟周圍組織，引起血容量不足，血壓下降（90/50 mmHg）是休克的早期跡象，需要立即補充輸液和升壓藥物。噁心嘔吐、疼痛、發燒雖是常見症狀，但低血壓的危急程度最高。
Acute pancreatitis can cause large amounts of fluid to shift from the vasculature into the tissues around the pancreas, leading to hypovolemia. A drop in blood pressure (90/50 mmHg) is an early sign of shock and requires immediate fluid replacement and vasopressor support. Although nausea and vomiting, pain, and fever are common symptoms, hypotension represents the most critical priority.
✦ 台美臨床差異
美國在急性胰臟炎的處置中，強調早期侵入性治療（如 ERCP）的時機；台灣亦然，但可能依病人穩定度及醫院設備決定。