— 生理適應 · HARD · MCQ —
對於甲狀腺機能亢進的病人，下列哪項評估發現護理師應優先回報給醫師？
Which assessment finding for a client with hyperthyroidism should the nurse prioritize reporting to the provider?
- ARestlessness and irritability煩躁不安與易怒
- BIncreased appetite食慾增加
- CHeart rate 130 beats/min with new atrial fibrillation✓ 正解心率 130 次/分伴隨新發心房顫動
- DWeight loss of 2 lbs體重減輕 2 磅
— Explanation · 中文詳解 —
甲狀腺機能亢進病人若心跳過快並伴隨心房顫動，提示發生甲狀腺風暴（Thyroid Storm）的可能性，此為致命性併發症。體重減輕與食慾增加是慢性表現，躁動也是常見症狀，但皆不如心律異常對生命威脅直接。
In a client with hyperthyroidism, tachycardia accompanied by atrial fibrillation suggests the possibility of thyroid storm, a life-threatening complication. Weight loss and increased appetite are chronic manifestations, and restlessness is a common symptom, but none of these pose as immediate a threat to life as the cardiac dysrhythmia.
✦ 台美臨床差異
美國護理師常有權力啟動 Rapid Response Team (RRT)，台灣則依層級回報，心律問題皆需即時處理。