— 生理適應 · MEDIUM · MCQ —
一位高鉀血症病人，下列哪項評估發現最為危急，需要立即處理？
A nurse is caring for a client with hyperkalemia. Which assessment finding is most concerning and requires immediate intervention?
- AReports of tingling sensations in fingers報告手指有刺痛感
- BMuscle weakness in lower extremities下肢肌肉無力
- CPeaked T waves on the ECG✓ 正解心電圖呈現高尖T波
- DDecreased bowel sounds腸蠕動音減弱
— Explanation · 中文詳解 —
高鉀血症對心臟電生理影響最大，ECG 出現高尖 T 波（Peaked T waves）是心律不整及致命性心跳停止的前兆。其他症狀如肌無力或腸蠕動變慢雖為常見表現，但其緊急程度遠低於心律改變，故優先針對心臟穩定進行處置。
Hyperkalemia has its greatest impact on cardiac electrophysiology, and peaked T waves on ECG are a harbinger of dysrhythmias and potentially fatal cardiac arrest. Other findings such as muscle weakness or decreased peristalsis are common manifestations, but their urgency is far lower than that of cardiac rhythm changes; therefore, cardiac stabilization takes priority.
✦ 台美臨床差異
美國護理師依據 protocol 可在發現心電圖異常時直接啟動緊急電解質處置程序，台灣通常需先通知住院醫師開立醫囑。