一位急性胰臟炎病人正接受靜脈輸液並禁食。護理師評估時發現 Trousseau 徵象為陽性。護理師應懷疑何種電解質失衡？
A client with acute pancreatitis is receiving IV fluids and is NPO. The nurse assesses the client and finds a positive Trousseau's sign. Which electrolyte imbalance should the nurse suspect?
- AHypocalcemia✓ 正解低血鈣
- BHypomagnesemia低血鎂
- CHyperkalemia高血鉀
- DHyponatremia低血鈉
Trousseau 徵象（測量血壓時手指痙攣）是低血鈣的典型臨床表現。急性胰臟炎時，脂肪壞死釋放的脂肪酸會與鈣離子結合形成皂化反應，導致血鈣濃度下降。此徵象對偵測早期低血鈣極具臨床敏感性，護理師應密切監測病人是否有喉頭痙攣或心律不整等嚴重併發症。
A positive Trousseau's sign (carpal spasm during blood pressure measurement) is a classic clinical manifestation of hypocalcemia. In acute pancreatitis, fatty acids released by fat necrosis bind with calcium ions in a saponification reaction, lowering serum calcium. This sign is highly sensitive for detecting early hypocalcemia, and the nurse should closely monitor the client for serious complications such as laryngospasm or cardiac dysrhythmias.
美國醫護對於急性胰臟炎的電解質監測非常積極，常設有警示界線；台灣臨床則多由醫師評估後再由護理師執行常規抽血。