— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病患主訴嚴重上腹痛，護理師應優先評估哪項指標，以偵測全身性併發症？
A client with acute pancreatitis reports severe epigastric pain. Which nursing assessment is the priority to evaluate for potential systemic complications?
- ASerum calcium levels血清鈣濃度
- BSkin turgor皮膚彈性
- CBlood pressure and heart rate✓ 正解血壓與心率
- DBowel sounds腸鳴音
— Explanation · 中文詳解 —
急性胰臟炎易導致血管滲透性增加、第三空間液體流失，引起低血容性休克。血壓下降與心跳過速是偵測循環衰竭最早期的生命徵象變化，應優先評估。其他選項雖為重要護理內容，但與維持灌流的急迫性相比，循環穩定度更直接關乎生命安全。
Acute pancreatitis readily increases vascular permeability and produces third-spacing of fluid, leading to hypovolemic shock. A drop in blood pressure and tachycardia are the earliest vital-sign changes signaling circulatory failure and should be assessed first. While the other options are important nursing concerns, maintaining perfusion takes precedence in terms of life safety.
✦ 台美臨床差異
美國護理師常執行快速評估（Rapid Assessment）流程，台灣臨床則較依賴醫師查房後的醫囑執行。