— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病患目前禁食且接受靜脈輸液。護理師觀察到下列何項評估數據應優先向醫師回報？
A client with acute pancreatitis is NPO and receiving IV fluids. Which assessment finding is the priority for the nurse to report to the provider?
- ASerum lipase level 500 units/L血清脂肪酶濃度 500 units/L
- BReports of 4/10 abdominal pain主訴腹部疼痛 4/10 分
- CHypocalcemia with a positive Chvostek's sign✓ 正解低血鈣伴隨 Chvostek 氏徵象陽性
- DBlood glucose 180 mg/dL血糖 180 mg/dL
— Explanation · 中文詳解 —
急性胰臟炎常見低血鈣合併症，Chvostek's sign 陽性反應代表神經肌肉過度興奮，嚴重恐致喉部痙攣及心律不整，威脅生命安全，故需優先處理。其餘選項雖不正常，但血糖稍高、輕度疼痛及胰臟酵素升高皆為該病之預期過程。
Acute pancreatitis is commonly complicated by hypocalcemia, and a positive Chvostek's sign indicates neuromuscular hyperexcitability, which can lead to severe laryngospasm and arrhythmias, posing a threat to life; it therefore requires priority management. The other options, although abnormal, are within the expected course of the disease: slightly elevated blood glucose, mild pain, and elevated pancreatic enzymes.
✦ 台美臨床差異
美國護理師常需負責評估 Chvostek/Trousseau sign；台灣醫護常依賴檢驗數據而非物理檢查發現低血鈣。