— 生理適應 · HARD · MCQ —
一名急性胰臟炎患者主訴劇烈腹痛，血清鈣濃度為 7.2 mg/dL。護理師應優先進行哪項評估？
A client with acute pancreatitis presents with severe abdominal pain and a serum calcium level of 7.2 mg/dL. Which nursing assessment is the priority?
- AMonitor for urinary output監測尿液輸出量
- BAssess for Chvostek's sign✓ 正解評估Chvostek氏徵象
- CEvaluate the skin for jaundice評估皮膚是否有黃疸
- DCheck for bowel sounds檢查腸鳴音
— Explanation · 中文詳解 —
低血鈣（<8.5 mg/dL）常見於胰臟炎，因為脂肪壞死會結合鈣質。Chvostek 徵象（敲擊面神經導致面部抽搐）是低血鈣引發神經肌肉激越性的典型指標。若不即時發現，可能進展至癲癇發作或喉頭痙攣，危及呼吸道安全，故列為優先評估項目。
Hypocalcemia (<8.5 mg/dL) is common in pancreatitis because fat necrosis sequesters calcium. Chvostek's sign (facial muscle twitching elicited by tapping the facial nerve) is a classic indicator of the neuromuscular irritability caused by hypocalcemia. If not identified promptly, it may progress to seizures or laryngospasm, threatening airway safety; it is therefore the priority assessment.
✦ 台美臨床差異
美國護理師常執行 Trousseau's 與 Chvostek's 徵象評估；台灣臨床較少於非神經外科病房執行此項測試。