— 降低風險 · HARD · MCQ —
護理師照護一位疑似嗜鉻細胞瘤的病人，下列哪項行動嚴格禁忌？
A nurse is caring for a client with a suspected pheochromocytoma. Which action is strictly contraindicated?
- AAdministering IV fluids給予靜脈輸液
- BMonitoring urine output監測尿液排出量
- CMeasuring blood pressure every 4 hours每 4 小時測量血壓
- DPalpating the abdomen✓ 正解觸診腹部
— Explanation · 中文詳解 —
嗜鉻細胞瘤是一種分泌兒茶酚胺的腫瘤。觸診腹部會刺激腫瘤大量釋放腎上腺素與去甲腎上腺素，誘發高血壓危象（Hypertensive Crisis），可能導致致命的腦出血或心律不整。因此在診斷確認前，嚴禁對腹部進行任何按壓。
Pheochromocytoma is a catecholamine-secreting tumor. Palpating the abdomen mechanically stimulates the tumor to release large amounts of epinephrine and norepinephrine, precipitating a hypertensive crisis that can result in fatal cerebral hemorrhage or arrhythmias. Therefore, any abdominal palpation is strictly contraindicated until the diagnosis is confirmed.
✦ 台美臨床差異
兩地對嗜鉻細胞瘤觸診的禁忌規範一致，皆列為護理安全教育中的重要警示項目。