— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病患有低血鈣風險。護理師在身體評估時應優先監測下列何種徵象？
A client with acute pancreatitis is at risk for hypocalcemia. Which assessment finding should the nurse prioritize during the examination?
- APresence of Homan's sign霍曼氏徵象的存在
- BPresence of Kernig's sign克尼格氏徵象的存在
- CPresence of Trousseau's sign✓ 正解特魯索氏徵象的存在
- DPresence of Brudzinski's sign布魯津斯基氏徵象的存在
— Explanation · 中文詳解 —
急性胰臟炎因脂肪壞死，鈣離子與脂肪酸結合導致低血鈣。Trousseau 徵象（測量血壓時手指痙攣）反映神經肌肉興奮性增加，是低血鈣的特徵性表現。其餘選項皆為神經學或血管系統檢查指標，與鈣離子失衡無直接關聯。
Acute pancreatitis can cause hypocalcemia due to calcium binding with fatty acids from fat necrosis. Trousseau's sign, characterized by carpal spasm induced by blood pressure cuff inflation, is a specific indicator of latent tetany resulting from increased neuromuscular excitability associated with low calcium levels.
✦ 台美臨床差異
美台臨床皆重視此評估，但美國護理評估更強調早期識別電解質失衡對心電圖 QT 間期的影響。