— 生理適應 · MEDIUM · SATA —
護理師在照顧高血鉀病人時，應預期出現哪些評估結果？（選所有適合的）
Which assessment findings should a nurse expect when caring for a client with hyperkalemia? (Select all that apply.)
- APeaked T waves on ECG✓ 正解心電圖出現尖峰 T 波
- BMuscle weakness or paralysis✓ 正解肌肉無力或麻痺
- CIncreased bowel sounds and diarrhea✓ 正解腸鳴音增加與腹瀉
- DDeep tendon hyperreflexia深層肌腱反射亢進
- EBradycardia✓ 正解心搏過緩
— Explanation · 中文詳解 —
高血鉀影響神經肌肉與心肌傳導。心電圖呈現 T 波高尖（Peaked T waves）；神經肌肉表現為無力或麻痺；腸胃道平滑肌亢進導致腹瀉與腸鳴音增加；心肌去極化受抑制導致心跳過慢。D 選項錯誤，通常表現為反射減弱而非亢進。
Hyperkalemia affects neuromuscular and cardiac conduction. The ECG typically shows peaked T waves; neuromuscular manifestations include weakness or paralysis; gastrointestinal smooth muscle hyperactivity leads to diarrhea and increased bowel sounds; and suppression of cardiac depolarization results in bradycardia. Option D is incorrect because hyperkalemia generally produces diminished, not hyperactive, deep tendon reflexes.
✦ 台美臨床差異
台美臨床對於高血鉀的緊急處理步驟一致，但美國護理師常依據 standing order 執行鈣劑給藥。