— 生理適應 · MEDIUM · MCQ —
護理師在評估急性胰臟炎病人時,哪項臨床發現需要立即介入?
A nurse is assessing a client with acute pancreatitis. Which clinical finding requires immediate intervention?
- AAbdominal pain radiating to the back腹部疼痛放射至背部
- BAbsent bowel sounds腸鳴音消失
- CRespirations of 28/min with crackles✓ 正解呼吸頻率 28 次/分伴隨囉音
- DSerum amylase level of 500 U/L血清澱粉酶濃度 500 U/L
— Explanation · 中文詳解 —
急性胰臟炎常見呼吸系統併發症,包括肺積水或呼吸窘迫症候群。呼吸過快且肺部出現濕囉音(crackles)暗示可能已發生肺部積液或肺水腫,影響氣體交換,是影響病人生存的急迫指標。其餘選項如腹痛或澱粉酶上升,均為胰臟炎的典型預期病程表現。
Acute pancreatitis commonly causes respiratory complications, including pleural effusion or acute respiratory distress syndrome. Tachypnea with crackles on lung auscultation suggests pulmonary fluid accumulation or pulmonary edema, which impairs gas exchange and is an urgent indicator threatening the client's survival. The remaining options, such as abdominal pain or elevated amylase, are typical expected manifestations of pancreatitis.
✦ 台美臨床差異
台灣針對此類病人多會執行更頻繁的血氧監測,美國則著重於多專科照護團隊的早期介入。