一位病人因診斷為嗜鉻細胞瘤（Pheochromocytoma）入院。護理計畫中最首要的介入措施是什麼？
A client is admitted with a diagnosis of pheochromocytoma. Which nursing intervention is the most important to include in the plan of care?
- AMonitor for signs of severe hypertension and headache✓ 正解監測嚴重高血壓和頭痛的跡象
- BPalpate the abdomen to check for adrenal masses觸診腹部以檢查腎上腺腫塊
- CRestrict fluid intake to prevent fluid overload限制液體攝取以防止液體過載
- DEncourage increased physical activity to reduce stress鼓勵增加體力活動以減輕壓力
嗜鉻細胞瘤是位於腎上腺髓質的腫瘤，會分泌大量的兒茶酚胺（腎上腺素與去甲腎上腺素），導致陣發性或持續性的嚴重高血壓。護理的首要任務是監測高血壓危象，這可能導致中風、心肌梗塞或器官衰竭。高血壓、劇烈頭痛、心悸與多汗被稱為嗜鉻細胞瘤的典型四聯症。特別注意：嚴禁觸摸或深壓病人的腹部（A 錯），因為這可能會機械性地擠壓腫瘤，導致兒茶酚胺猛然釋放到血液中，引發致命的高血壓。此外，這類病人需要安靜休息而非增加活動（C 錯），以減少交感神經刺激。此題強調病理生理與安全禁忌的連結。臨床思路應聚焦於預防急劇的血壓波動，任何可能誘發兒茶酚胺釋放的行為（如觸診、壓力、情緒激動）都應避免。
Pheochromocytoma is a tumor of the adrenal medulla that secretes large amounts of catecholamines (epinephrine and norepinephrine), causing paroxysmal or sustained severe hypertension. The nursing priority is monitoring for hypertensive crisis, which can lead to stroke, myocardial infarction, or organ failure. Hypertension, severe headache, palpitations, and diaphoresis are referred to as the classic 'tetrad' of pheochromocytoma. Of particular note: palpating or deeply pressing on the client's abdomen is strictly prohibited (Option B is incorrect), because it may mechanically compress the tumor and trigger a sudden release of catecholamines into the bloodstream, precipitating a fatal hypertensive crisis. In addition, these clients require quiet rest rather than increased activity (Option D is incorrect) in order to minimize sympathetic stimulation. This question highlights the link between pathophysiology and safety contraindications. Clinical reasoning should focus on preventing acute fluctuations in blood pressure; any behavior that may trigger catecholamine release (palpation, stress, emotional excitement) should be avoided.
美國護理指引中，對於嗜鉻細胞瘤病人的床頭常會貼上「Do Not Palpate Abdomen」的警示標語，這是標準的安全文化；台灣臨床雖然也知道此禁忌，但在護理評估表格中可能較少有專屬的顯眼警示，需靠護理師的專業知識主動落實。