— 降低風險 · MEDIUM · SATA —
一位病人被診斷為高血鉀，護理師應優先評估下列哪些徵象？（選所有適合的）
A client is diagnosed with hyperkalemia. Which assessment findings should the nurse prioritize? (Select all that apply.)
- AIrregular pulse✓ 正解心律不整
- BMuscle twitching or weakness✓ 正解肌肉抽搐或無力
- CHyperactive bowel sounds✓ 正解腸鳴音亢進
- DIncreased urine output尿量增加
- ETall, peaked T-waves on ECG✓ 正解心電圖呈現高尖 T 波
— Explanation · 中文詳解 —
高血鉀會影響神經肌肉及心肌電氣傳導。心臟影響包括心律不整及 ECG 出現高尖 T 波；神經肌肉症狀包括震顫、虛弱及腸蠕動亢進（腹瀉、痙攣）。尿量增加並非高血鉀的直接臨床徵象，高血鉀反而常與腎功能惡化相關。
Hyperkalemia affects neuromuscular function and cardiac electrical conduction. Cardiac effects include dysrhythmias and tall, peaked T waves on the ECG; neuromuscular symptoms include twitching, weakness, and increased GI motility (diarrhea, cramping). Increased urine output is not a direct clinical sign of hyperkalemia; rather, hyperkalemia is commonly associated with worsening renal function.
✦ 台美臨床差異
美國護理師常需在緊急情況下依據醫囑執行降鉀處置（如胰島素給藥）；台灣則多由醫師評估後開立醫囑執行。