— 生理適應 · MEDIUM · MCQ —
護理師照顧一位新診斷為低血鉀的病人，評估時應優先注意下列哪項發現？
A nurse is caring for a client with a new diagnosis of hypokalemia. Which finding should the nurse prioritize during the assessment?
- ADry mucous membranes黏膜乾燥
- BMuscle weakness肌肉無力
- CDecreased bowel sounds腸蠕動音減少
- DIrregular heart rhythm✓ 正解心律不整
— Explanation · 中文詳解 —
低血鉀影響心肌細胞電位，導致心律不整甚至致命的心室纖維顫動。雖然肌肉無力和腸蠕動變慢也是典型症狀，但心律改變直接威脅生命（ABC 原則中的 Circulation），故為優先評估項目。黏膜乾燥與鉀離子失衡無直接關係，需從體液容積狀態判斷。
Hypokalemia affects cardiac myocyte electrical activity, causing arrhythmias and even lethal ventricular fibrillation. Although muscle weakness and decreased bowel sounds are also typical, cardiac rhythm changes directly threaten life (Circulation in ABC), making them the priority finding. Dry mucous membranes are unrelated to potassium imbalance and reflect volume status.
✦ 台美臨床差異
兩地皆高度重視低血鉀引起的心臟併發症，台灣醫療環境更強調護理師對心電圖監測報告的判讀能力。