— 生理適應 · MEDIUM · MCQ —
一名急性胰臟炎病人有低血鈣風險，護理師應監測何種臨床表徵？
A client with acute pancreatitis is at risk for hypocalcemia. Which clinical manifestation should the nurse monitor for?
- AHyperactive bowel sounds腸鳴音亢進
- BTrousseau's sign✓ 正解特魯索氏徵象
- CPolyuria多尿
- DFlaccid paralysis弛緩性麻痺
— Explanation · 中文詳解 —
低血鈣常發生於急性胰臟炎，原因為脂肪壞死與鈣離子皂化。特徵包含神經肌肉興奮性增加，如 Trousseau's sign（壓脈帶打氣後手腕抽搐）或 Chvostek's sign。選項 D 為高血鉀；A 則多見於腹瀉或初期腸阻塞；C 則通常與糖尿病或高血糖相關。
Hypocalcemia frequently occurs in acute pancreatitis, caused by fat necrosis and saponification with calcium ions. Features include increased neuromuscular excitability, such as Trousseau's sign (carpal spasm after blood pressure cuff inflation) and Chvostek's sign. Option D reflects hyperkalemia; option A is more commonly seen in diarrhea or early intestinal obstruction; option C is usually associated with diabetes or hyperglycemia.
✦ 台美臨床差異
美台臨床皆重視低血鈣引發的抽搐評估，但美國護理師評估神經肌肉興奮性較為常規，台灣臨床亦常依賴醫師診斷。