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生理適應 · MEDIUM · SATA

病人被診斷為低血鉀,護理師在身體評估時應預期發現哪些徵象?(選所有適合的)

A client is diagnosed with hypokalemia. Which manifestations should the nurse expect to find during physical assessment? (Select all that apply.)

  • AMuscle weakness and fatigue✓ 正解
    肌肉無力與疲倦
  • BDecreased bowel sounds✓ 正解
    腸音減弱
  • CHyperactive deep tendon reflexes
    深部腱反射亢進
  • DCardiac dysrhythmias✓ 正解
    心律不整
  • EHypoactive bowel sounds or paralytic ileus✓ 正解
    腸音減弱或麻痺性腸阻塞
Explanation · 中文詳解

低血鉀會影響神經肌肉傳導與平滑肌功能。肌肉無力與疲勞源於靜止膜電位改變;腸蠕動變慢導致腸音減弱,嚴重者可併發麻痺性腸阻塞;心肌細胞興奮性受影響,易引發心律不整。反射亢進(C)通常與高血鈣或高血鎂相關,非低血鉀典型表現。

Hypokalemia affects neuromuscular conduction and smooth muscle function. Muscle weakness and fatigue result from changes in resting membrane potential; slowed bowel motility leads to diminished bowel sounds, and severe cases may progress to paralytic ileus; myocardial cell excitability is also affected, predisposing to arrhythmias. Hyperreflexia (C) is usually associated with hypercalcemia or hypermagnesemia and is not a typical manifestation of hypokalemia.

✦ 台美臨床差異

美國護理師常依據檢驗報告直接給予口服鉀補充,台灣多數醫療機構需醫師開立醫囑後方可執行。

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