— 生理適應 · MEDIUM · MCQ —
護理師照護一位患有第一型糖尿病且發生酮酸中毒（DKA）的病人。哪項評估發現最符合此診斷？
A nurse is caring for a client with Type 1 Diabetes Mellitus who has developed DKA. Which assessment finding is most consistent with this diagnosis?
- APresence of pedal edema足部水腫
- BSerum potassium level of 5.5 mEq/L血清鉀濃度 5.5 mEq/L
- CBlood glucose level of 120 mg/dL血糖濃度 120 mg/dL
- DDeep, rapid, labored respirations✓ 正解深快且費力的呼吸
— Explanation · 中文詳解 —
DKA 病人因代謝性酸中毒，身體會透過 Kussmaul 呼吸（深且快）代償以排出二氧化碳。血糖通常大於 250 mg/dL，C 選項數值偏低。鉀離子在發病初期可能正常或偏高，但並非診斷 DKA 的特徵性呼吸表徵。水腫與 DKA 無直接相關。
Because of metabolic acidosis, clients with DKA compensate with Kussmaul respirations (deep and rapid breathing) to eliminate carbon dioxide. Blood glucose is typically greater than 250 mg/dL, making option C too low. Potassium may be normal or elevated at the onset of DKA, but it is not a characteristic respiratory feature for diagnosis. Edema is not directly related to DKA.
✦ 台美臨床差異
台美臨床對於 DKA 的胰島素治療 protocol 相似，均需嚴格監測心電圖以防低血鉀。