— 生理適應 · MEDIUM · MCQ —
一位病人診斷為低血鉀，下列哪項護理評估發現最令人擔憂？
A client is diagnosed with hypokalemia. Which nursing assessment finding is most concerning?
- AMuscle cramps in the lower extremities下肢肌肉痙攣
- BPolyuria多尿
- CDecreased bowel sounds腸鳴音減弱
- DIrregular, thready pulse✓ 正解脈搏不規則且細弱
— Explanation · 中文詳解 —
低血鉀（Hypokalemia）會干擾心肌細胞的電生理活動，導致心室再極化延遲，臨床上表現為心律不整。在護理評估中，ABC原則（Airway, Breathing, Circulation）始終優先，心血管功能異常直接威脅生命，因此不規則且微弱的脈搏（Irregular, thready pulse）是最需緊急處理的發現。其餘選項雖為低血鉀之常見症狀，但皆屬於慢性或非立即致命的生理反應。
An irregular, thready pulse is the most concerning finding in hypokalemia because low potassium levels disrupt cardiac electrical activity, potentially leading to life-threatening dysrhythmias. According to ABC priorities, circulatory instability takes precedence over other symptoms like muscle cramps, polyuria, or decreased bowel sounds. Immediate assessment and correction are required to prevent cardiac arrest.