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生理適應 · EASY · MCQ

一位糖尿病患被發現意識不清,皮膚濕冷。下列何者為優先護理措施?

A client with diabetes mellitus is found unconscious with cold, clammy skin. Which intervention is the priority?

  • ACheck the client's blood glucose level✓ 正解
    測量病人的血糖值
  • BAdminister subcutaneous regular insulin
    給予皮下注射常規胰島素
  • CPerform a neurological assessment
    進行神經學評估
  • DProvide a glass of orange juice
    提供一杯柳橙汁
Explanation · 中文詳解

糖尿病病人若出現意識不清且皮膚濕冷(Cold, clammy skin),這通常是嚴重低血糖(Hypoglycemia)的典型表現。冷汗是交感神經被活化的結果。護理師的首要行動是立即確認血糖值(Check blood glucose),以證實是否為低血糖。確認後才能採取正確的靜脈葡萄糖給予,切勿在病人無意識時給予口服食物,以免造成窒息。

When a client with diabetes is found unconscious with cold, clammy skin, this is typically the classic presentation of severe hypoglycemia. The cold sweat is the result of sympathetic nervous system activation. The nurse's first action is to immediately check the blood glucose level to confirm hypoglycemia. Only after confirmation can intravenous glucose be administered appropriately; oral intake must never be given to an unconscious client because of the risk of aspiration.

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