— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病患出現嚴重腹痛、噁心與嘔吐。護理師應優先監測哪種電解質失衡？
A client with acute pancreatitis presents with severe abdominal pain, nausea, and vomiting. Which electrolyte imbalance should the nurse prioritize monitoring?
- AHypocalcemia✓ 正解低血鈣
- BHyponatremia低血鈉
- CHyperkalemia高血鉀
- DHypermagnesemia高血鎂
— Explanation · 中文詳解 —
急性胰臟炎時，脂肪酶釋放會分解脂肪並與鈣離子結合（皂化反應），導致血清鈣下降。低血鈣會增加神經肌肉興奮性，誘發特魯索氏徵象（Trousseau's sign）或手足抽搐，嚴重時引發心律不整，因此監測鈣離子是照顧此類病人的關鍵。
In acute pancreatitis, lipase release breaks down fats that bind with calcium ions (saponification), lowering serum calcium. Hypocalcemia increases neuromuscular excitability, producing Trousseau's sign or tetany, and in severe cases arrhythmias. Monitoring calcium is therefore critical when caring for these clients.
✦ 台美臨床差異
美國護理師常執行床邊評估（如 Chvostek's sign），台灣常依賴醫囑抽血檢測，床邊評估執行率較低。