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心理社會完整性 · HARD · SATA

護理師照顧患有厭食症的病人,評估時需優先關注哪些發現?(選所有適合的)

A nurse is caring for a client with anorexia nervosa. Which findings should the nurse prioritize during assessment? (Select all that apply.)

  • APotassium level of 2.8 mEq/L✓ 正解
    鉀離子濃度 2.8 mEq/L
  • BPulse rate of 42 beats per minute✓ 正解
    脈搏 42 次/分鐘
  • CPresence of lanugo on the face
    面部出現胎毛
  • DBlood pressure of 88/50 mmHg✓ 正解
    血壓 88/50 mmHg
  • EPeripheral edema in the lower extremities✓ 正解
    下肢周邊水腫
Explanation · 中文詳解

厭食症病人常伴隨嚴重的代謝紊亂與心血管問題。低血鉀(A)增加心律不整風險;心搏過緩(B)與低血壓(D)為循環衰竭的徵兆;周邊水腫(E)常因營養不良導致低白蛋白血症引起。胎毛(C)雖為常見徵象,但在緊急醫療處置優先級中低於上述生理不穩定徵象。

Clients with anorexia nervosa frequently present with severe metabolic and cardiovascular abnormalities. Hypokalemia (A) increases the risk of dysrhythmias; bradycardia (B) and hypotension (D) are signs of circulatory failure; peripheral edema (E) often results from hypoalbuminemia secondary to malnutrition. Although lanugo (C) is a common finding, it ranks below these physiologically unstable findings in the urgency of emergency medical management.

✦ 台美臨床差異

美國有專責飲食失調病房;台灣厭食症病人通常收治於一般內科或精神科,較缺乏跨專業飲食治療小組。

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