— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病人出現嚴重腹痛、噁心與嘔吐。哪項評估發現需要護理師最優先處理？
A client with acute pancreatitis presents with severe abdominal pain, nausea, and vomiting. Which assessment finding requires the most immediate intervention by the nurse?
- ASerum amylase level of 800 U/L血清澱粉酶濃度為800 U/L
- BReports of 8/10 pain intensity報告疼痛強度為8/10
- CAbdominal distention with absent bowel sounds腹部膨脹且腸鳴音消失
- DBlood pressure of 88/50 mmHg✓ 正解血壓為88/50 mmHg
— Explanation · 中文詳解 —
急性胰臟炎（Acute pancreatitis）的病理特徵是胰臟酵素外漏，導致周邊組織廣泛發炎與體液流失至第三間隙（Third spacing）。這會導致嚴重的低血容積休克（Hypovolemic shock）。護理優先順序為維持循環穩定（ABC 原則），低血壓（88/50 mmHg）顯示病人已出現休克徵象，需立即給予輸液復甦。
Acute pancreatitis is pathologically characterized by leakage of pancreatic enzymes, leading to widespread surrounding tissue inflammation and fluid loss into the third space. This may produce severe hypovolemic shock. The nursing priority is to maintain circulatory stability (ABC principle); a blood pressure of 88/50 mmHg indicates that the client is in shock and requires immediate fluid resuscitation.