— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病人出現低血鈣症狀。護理師在理學檢查中應優先評估下列哪項徵象？
A client with acute pancreatitis is exhibiting signs of hypocalcemia. Which assessment finding should the nurse prioritize during the examination?
- AFlattened T-waves on ECG心電圖上 T 波平坦
- BPositive Trousseau sign✓ 正解特魯索氏徵象（Trousseau sign）陽性
- CAbsent bowel sounds腸音消失
- DPeripheral edema周邊水腫
— Explanation · 中文詳解 —
急性胰臟炎常見脂肪壞死導致血鈣下降，Trousseau 徵象（BP 袖帶充氣後出現手部痙攣）是神經肌肉過度興奮的特異性指標。B 是低血鉀，C 與腹膜刺激有關，D 與水份過負荷有關，優先排除危及生命的肌肉痙攣或喉頭痙攣風險。
Acute pancreatitis commonly leads to fat necrosis and a drop in serum calcium. Trousseau's sign (carpal spasm after inflation of a BP cuff) is a specific indicator of neuromuscular hyperexcitability. B reflects hypokalemia, C is related to peritoneal irritation, and D is associated with fluid overload. The priority is to rule out life-threatening muscle spasm or laryngospasm.
✦ 台美臨床差異
美國護理師在 ICU/急診常執行此項評估；台灣護理師執行頻率較低，多依賴醫師指示執行完整理學評估。