— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病人正接受靜脈輸液且禁食（NPO）。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 intervention by the nurse?
- AHeart rate 88 beats/min心率 88 次/分
- BSerum lipase level elevated血清脂肪酶水平升高
- CBlood glucose 150 mg/dL血糖 150 mg/dL
- DPositive Trousseau's sign✓ 正解Trousseau 徵呈陽性
— Explanation · 中文詳解 —
急性胰臟炎常見低血鈣現象，這是因為脂肪壞死與鈣離子結合（皂化作用）。Trousseau's sign 是低血鈣的特徵性體徵，暗示可能出現嚴重的肌肉痙攣或喉頭痙攣，具有潛在生命危險。選項 C 與 B 為疾病的預期病程，A 在正常範圍內。
Acute pancreatitis is frequently complicated by hypocalcemia because of fat necrosis and binding of calcium ions (saponification). Trousseau's sign is a hallmark of hypocalcemia and indicates the potential for severe muscle spasm or laryngospasm, which is life-threatening. Options C and B are expected findings of the disease course, and option A is within normal limits.
✦ 台美臨床差異
美國護理師常依實驗室數值直接執行鈣片給藥，台灣臨床多需醫師開立醫囑後才給予補鈣。