— 生理適應 · MEDIUM · SATA —
護理師照護一位高血鉀症病人，應監測哪些臨床發現？（選所有適合的）
A nurse is caring for a client with hyperkalemia. Which assessment findings should the nurse monitor for? (Select all that apply.)
- APeaked T waves on ECG✓ 正解心電圖上出現尖銳T波
- BMuscle weakness or paralysis✓ 正解肌肉無力或麻痺
- CIncreased bowel sounds/diarrhea✓ 正解腸鳴音增加/腹瀉
- DU-waves on ECG心電圖上出現U波
- EHypoactive deep tendon reflexes深層腱反射減弱
— Explanation · 中文詳解 —
高血鉀對心臟與神經肌肉系統影響顯著。心電圖常見 T 波高聳（Peaked T waves）；神經肌肉方面會導致肌肉無力或麻痺；胃腸道因平滑肌受刺激，常見腸音亢進與腹瀉。U 波為低血鉀表現，深部肌腱反射增強或亢進才與高血鉀相關（早期），Hypoactive 反射通常見於低血鉀。
Hyperkalemia significantly affects cardiac and neuromuscular systems. ECG shows peaked T waves; neuromuscularly, weakness or paralysis is common; GI smooth-muscle stimulation produces increased bowel sounds and diarrhea. U waves indicate hypokalemia, not hyperkalemia. Early hyperkalemia is associated with hyperactive (not hypoactive) deep tendon reflexes; hypoactive reflexes are more typical of hypokalemia.
✦ 台美臨床差異
美國常使用監測儀即時評估，台灣則依賴醫師判讀心電圖報告較多，但護理師皆需具備辨識危險波型能力。