— 生理適應 · EASY · MCQ —
一位急性胰臟炎病人表現出嚴重上腹痛。下列哪項評估結果需要護理師立即關注？
A client with acute pancreatitis presents with severe epigastric pain. Which assessment finding requires the nurse's immediate attention?
- AHypotension and tachycardia✓ 正解低血壓與心跳過速
- BBlood glucose of 180 mg/dL血糖 180 mg/dL
- CElevated serum amylase血清澱粉酶升高
- DAbsent bowel sounds腸鳴音消失
— Explanation · 中文詳解 —
急性胰臟炎的嚴重併發症包括低血容性休克、全身性發炎反應症候群（SIRS）與器官衰竭。低血壓伴隨心跳過速（A）是循環衰竭的預兆，代表病人正處於低血容狀態，這對生命構成直接威脅，必須立即處置。其他選項雖為異常（高血糖、腸阻塞、澱粉酶升高），但皆屬於胰臟炎的常見病程，其緊急程度遠低於血流動力學不穩定的休克狀態。
Severe complications of acute pancreatitis include hypovolemic shock, SIRS, and organ failure. Hypotension with tachycardia (A) heralds circulatory failure, indicating the client is in a hypovolemic state—a direct life threat requiring immediate intervention. Other findings, though abnormal (hyperglycemia, paralytic ileus, elevated amylase), are common in the disease course and far less urgent than hemodynamic instability.