— 生理適應 · MEDIUM · SATA —
一位第一型糖尿病病人診斷為糖尿病酮酸中毒(DKA)。護理師應預期看到哪些表現?(選所有適合的)
A nurse is caring for a client with Type 1 Diabetes Mellitus who presents with DKA. Which assessment findings should the nurse expect? (Select all that apply.)
- AKussmaul respirations✓ 正解庫斯莫爾氏呼吸(Kussmaul respirations)
- BFruity breath odor✓ 正解果味口臭
- CBlood glucose level < 70 mg/dL血糖水平 < 70 mg/dL
- DMetabolic alkalosis代謝性鹼中毒
- ESerum ketone presence✓ 正解血清酮體存在
— Explanation · 中文詳解 —
DKA 呈現高血糖、酸中毒與酮體堆積。Kussmaul 呼吸是為了代償代謝性酸中毒而出現的深快呼吸;酮體分解產生丙酮導致爛蘋果味氣息;驗血或尿會出現酮體陽性。C 錯在 DKA 是高血糖;D 錯在這是代謝性酸中毒。
Diabetic ketoacidosis (DKA) is characterized by hyperglycemia, metabolic acidosis, and ketone production. Expected findings include Kussmaul respirations to compensate for acidosis, a fruity breath odor from acetone, and positive serum ketones due to fat breakdown.
✦ 台美臨床差異
無顯著差異。