— 生理適應 · MEDIUM · MCQ —
一位病人因糖尿病酮酸中毒（DKA）入院。護理師應預期評估到哪項臨床發現？
A client is admitted with diabetic ketoacidosis (DKA). Which clinical finding should the nurse expect to assess?
- ABradycardia心搏過緩
- BKussmaul respirations✓ 正解庫斯莫爾呼吸
- CSevere hypoglycemia嚴重低血糖
- DWeight gain體重增加
— Explanation · 中文詳解 —
DKA 病人因酸中毒，呼吸代償機制會出現深而快的 Kussmaul 呼吸，以呼出二氧化碳調節 pH 值。病人通常會有脫水導致體重下降而非增加，且呈現高血糖而非低血糖；心跳通常因脫水而代償性增加（心搏過速）而非過慢。
Clients with diabetic ketoacidosis (DKA) typically exhibit Kussmaul respirations, characterized by deep and rapid breathing, as a compensatory mechanism to blow off carbon dioxide and correct metabolic acidosis. Other expected findings include tachycardia due to dehydration, weight loss from fluid loss, and hyperglycemia rather than hypoglycemia.
✦ 台美臨床差異
美國護理師常依 DKA Protocol 執行連續靜脈輸注胰島素；台灣臨床較依賴醫師持續監測與調整。