— 生理適應 · MEDIUM · MCQ —
病人診斷為低血鈣，護理師需評估 Trousseau's 徵象，應如何執行？
A client is diagnosed with hypocalcemia. The nurse assesses for Trousseau's sign. How is this performed?
- ATap the facial nerve in front of the ear輕敲耳前的顏面神經
- BObserve for muscle twitching in the lower extremities觀察下肢是否有肌肉抽搐
- CInflate a blood pressure cuff above systolic pressure✓ 正解將血壓計袖帶充氣超過收縮壓
- DStroke the cheek near the facial nerve輕撫靠近顏面神經的臉頰
— Explanation · 中文詳解 —
低血鈣（Hypocalcemia）會導致神經肌肉興奮性增加。Trousseau's 徵象是一種評估潛在手足抽搐（Tetany）的方法。透過限制手臂血流，誘發缺血性神經興奮，若出現助產士手（Carpal spasm）則為陽性。這是在臨床評估低血鈣病人時，與 Chvostek's 徵象並列的兩大經典物理檢查。
Trousseau's sign is assessed by inflating a blood pressure cuff on the arm above systolic pressure for several minutes to induce carpal spasm, indicating neuromuscular irritability from hypocalcemia. Tapping or stroking the facial nerve evaluates Chvostek's sign, which is a different indicator of hypocalcemia.