— 生理適應 · MEDIUM · SATA —
護理師評估一位診斷為低血鉀的病人，下列哪些是預期出現的臨床表徵？（選所有適合的）
A client is diagnosed with hypokalemia. Which manifestations should the nurse expect to assess? (Select all that apply.)
- AMuscle weakness and cramping✓ 正解肌無力和痙攣
- BHypoactive bowel sounds✓ 正解腸蠕動音減弱
- CTall, peaked T waves on ECG心電圖上出現高大尖聳的T波
- DCardiac dysrhythmias✓ 正解心律不整
- EMental confusion✓ 正解精神混亂
— Explanation · 中文詳解 —
低血鉀影響細胞膜電位，導致神經肌肉與腸胃道傳導變慢。肌肉無力與痙攣是常見症狀；腸胃蠕動減弱導致腸音變小；心臟節律異常是嚴重併發症；電解質不平衡亦可能導致神經精神症狀如意識模糊。尖聳 T 波是高血鉀特徵。
Hypokalemia alters cellular membrane potentials, slowing neuromuscular and gastrointestinal conduction. Muscle weakness and cramping are common manifestations; reduced gastrointestinal motility produces hypoactive bowel sounds; cardiac dysrhythmias are a serious complication; and electrolyte imbalance may also produce neuropsychiatric symptoms such as confusion. Tall, peaked T waves are a hallmark of hyperkalemia rather than hypokalemia.
✦ 台美臨床差異
美國護理師常主動執行心電圖監測，台灣則多依據醫師開立之檢查醫囑執行。