— 生理適應 · HARD · MCQ —
一位急性胰臟炎病人的血清鈣濃度為 7.2 mg/dL。護理師應預期出現何種身體評估結果？
A client with acute pancreatitis presents with a serum calcium level of 7.2 mg/dL. Which physical assessment finding should the nurse anticipate?
- AMuscle weakness and lethargy肌肉無力和嗜睡
- BFlattened T-waves on ECG心電圖上T波平坦
- CPositive Trousseau's sign✓ 正解Trousseau徵象陽性
- DHyperactive bowel sounds腸鳴音亢進
— Explanation · 中文詳解 —
低血鈣（正常值 8.5-10.5 mg/dL）會導致神經肌肉興奮性增加。Trousseau 徵象（測量血壓時出現手部痙攣）是低血鈣的經典臨床表現。D 選項多見於高腸蠕動；B 選項為低血鉀表現；A 選項多見於高血鈣。
Hypocalcemia (normal range 8.5-10.5 mg/dL) increases neuromuscular excitability. Trousseau's sign (carpopedal spasm elicited by blood pressure cuff inflation) is a classic clinical manifestation of hypocalcemia. Option D is more typical of increased intestinal motility; option B reflects hypokalemia; option A is more characteristic of hypercalcemia.
✦ 台美臨床差異
台美臨床均重視此評估，但在美 NCLEX 考題中特別強調電解質不平衡的神經肌肉影響，台灣臨床則更依賴檢驗報告。