— 生理適應 · EASY · MCQ —
護理師照顧一位腹膜炎病人。哪項評估發現是此疾病最典型的特徵？
A nurse is caring for a client with peritonitis. Which assessment finding is most characteristic of this condition?
- AHyperactive bowel sounds腸鳴音亢進
- BSoft, non-tender abdomen腹部柔軟、無壓痛
- CRigid, board-like abdomen✓ 正解腹部僵硬、呈木板狀
- DFrequent loose stools頻繁排出稀便
— Explanation · 中文詳解 —
腹膜炎 (Peritonitis) 是腹膜的發炎，通常是由於腹腔內器官穿孔、感染或化學刺激所引起。腹膜炎是一種嚴重的醫療急症，其特徵是劇烈的腹痛和腹部壓痛。由於腹膜受到刺激，腹壁肌肉會反射性地收縮和僵硬，試圖保護發炎的腹腔器官，這種現象稱為肌肉僵硬 (guarding)。這種僵硬程度可以非常顯著，使得觸診時腹部感覺像木板一樣堅硬。護理師必須立即辨識此典型體徵，因其常指示需要緊急手術介入。
A rigid, board-like abdomen is the most characteristic finding in peritonitis, resulting from involuntary muscle guarding due to severe peritoneal inflammation. Bowel sounds are typically diminished or absent, and the abdomen is tender rather than soft. This sign indicates a medical emergency often requiring prompt surgical evaluation.