— 生理適應 · EASY · MCQ —
一位 45 歲第一型糖尿病病人出現混亂、盜汗與心搏過速。護理師應立即採取哪項行動？
A 45-year-old client with Type 1 diabetes mellitus is found confused, diaphoretic, and tachycardic. Which immediate action should the nurse take?
- AObtain a venous blood sample for lab analysis取得靜脈血液樣本進行檢驗
- BCheck the client's blood glucose level✓ 正解測量病人血糖值
- CAdminister glucagon intramuscularly肌肉注射升糖素
- DAdminister 15-20 grams of rapid-acting carbohydrates給予 15-20 公克快速作用的碳水化合物
— Explanation · 中文詳解 —
第一型糖尿病病人若出現混亂、盜汗與心搏過速，這明顯是低血糖（Hypoglycemia）的徵兆。護理師的首要行動是立即確認血糖值（Check blood glucose），因為這能確認診斷並指導後續處置（如給予糖水或注射升糖素）。直接給予糖水雖然是治療低血糖的方式，但必須先經由血糖數值確認，以確保安全與避免誤診。在 NCLEX 考試中，Assessment（評估）幾乎永遠優於 Intervention（介入）。
In a Type 1 diabetic with confusion, diaphoresis, and tachycardia, hypoglycemia is highly suspected. The nurse's first action is to check the blood glucose level to confirm the diagnosis and guide treatment (oral carbohydrates or glucagon). Assessment precedes intervention in NCLEX prioritization unless the patient is unresponsive.