— 生理適應 · HARD · MCQ —
一位病人因糖尿病酮酸中毒（DKA）入院，何種護理評估符合代謝性酸中毒的代償反應？
A client is admitted with diabetic ketoacidosis (DKA). Which nursing assessment finding is consistent with the compensatory response to metabolic acidosis?
- AApnea呼吸暫停
- BKussmaul respirations✓ 正解庫斯莫爾氏呼吸（Kussmaul respirations）
- CShallow breathing淺層呼吸
- DBradypnea呼吸過緩
— Explanation · 中文詳解 —
代謝性酸中毒時，身體透過肺部排出二氧化碳（酸性）來代償 pH 值，表現為深而快的呼吸，稱為 Kussmaul 呼吸。其他選項皆為換氣不足，會加重酸中毒情況。此為重要的生理適應機制，護理師需區分其與正常呼吸模式之不同。
In metabolic acidosis, the body compensates by eliminating carbon dioxide (an acid) through the lungs, manifested as deep, rapid breathing known as Kussmaul respirations. The other options reflect hypoventilation, which would worsen the acidosis. This is an important physiologic adaptation, and the nurse must distinguish it from normal breathing patterns.
✦ 台美臨床差異
美台臨床皆強調對於 Kussmaul 呼吸的辨識，此徵象常是 DKA 嚴重程度的臨床指標，護理師需具備敏銳觀察力。