— 生理適應 · MEDIUM · MCQ —
一名急性胰臟炎病患出現嚴重腹痛，下列哪項評估發現需要護理師立即關注？
A client with acute pancreatitis presents with severe abdominal pain. Which assessment finding requires the nurse's immediate attention?
- AModerate upper abdominal pain中度上腹部疼痛
- BElevated serum amylase levels血清澱粉酶水平升高
- CAbsent bowel sounds腸蠕動音消失
- DHypotension and tachycardia✓ 正解低血壓和心搏過速
— Explanation · 中文詳解 —
急性胰臟炎（Acute Pancreatitis）會引發嚴重的全身性發炎反應（SIRS），導致血管通透性增加，液體從血管內滲出至第三空間（Third spacing），造成嚴重的低血容休克。低血壓（Hypotension）與心跳過速（Tachycardia）是血液動力學不穩定的徵兆，可能導致器官灌流不足甚至衰竭，需立即採取補液措施（Fluid resuscitation）。
Hypotension and tachycardia are critical signs of hypovolemic shock caused by third-spacing of fluids in acute pancreatitis. This hemodynamic instability requires immediate fluid resuscitation to prevent organ failure. While pain and elevated enzymes are expected, they do not pose the same immediate life-threatening risk as shock.