一位急性胰臟炎病人正在接受靜脈輸液並禁食。下列哪項評估結果需要護理師立即介入？
A client with acute pancreatitis is receiving IV fluids and is NPO. Which assessment finding requires immediate nursing intervention?
- APositive Trousseau's sign✓ 正解特魯索氏徵象（Trousseau's sign）呈陽性
- BSerum lipase level elevated血清脂肪酶（lipase）濃度升高
- CAbsent bowel sounds腸蠕動音消失
- DReports of 6/10 abdominal pain主訴腹痛程度為 6/10
急性胰臟炎病人常見鈣質流失（脂肪皂化反應），導致低血鈣。Trousseau's sign 陽性代表神經肌肉過度敏感，是低血鈣的危險徵象，可能引發喉頭痙攣或心律不整，需優先處理。A 為禁食常見現象；C 為診斷指標；D 需處置但非立即生命威脅。
Clients with acute pancreatitis often experience calcium loss (through fat saponification), leading to hypocalcemia. A positive Trousseau's sign reflects neuromuscular hyperexcitability and is a dangerous sign of hypocalcemia that may precipitate laryngospasm or cardiac dysrhythmia, requiring priority management. Option C is a common finding in the NPO state; B is a diagnostic marker; D requires treatment but is not immediately life-threatening.
美國護理師在監測 Trousseau's sign 後通常可依協定抽血確認，台灣需醫師開立醫囑。