— 生理適應 · HARD · SATA —
護理師照護一位新診斷為代謝性酸中毒的病人，預期會觀察到哪些徵象？（選所有適合的）
A nurse is caring for a client with a new diagnosis of metabolic acidosis. Which assessment findings should the nurse expect? (Select all that apply.)
- AKussmaul respirations✓ 正解庫斯莫爾氏呼吸（Kussmaul respirations）
- BBradycardia心搏過緩
- CHyperkalemia✓ 正解高血鉀症
- DLethargy or confusion✓ 正解嗜睡或意識混亂
- EWarm and flushed skin✓ 正解皮膚溫暖且潮紅
— Explanation · 中文詳解 —
代謝性酸中毒（Metabolic Acidosis）的核心病理是體內碳酸氫根（HCO3-）流失或酸性代謝產物堆積，導致 pH 值下降。身體會啟動代償機制以維持酸鹼平衡，包括呼吸系統代償及電解質轉移。護理師需評估呼吸代償徵象、評估神經系統狀態（酸中毒會抑制中樞神經），並監測電解質變化。臨床上，優先考慮呼吸型態與神經功能，並預防高血鉀引起的潛在心律不整。
In metabolic acidosis, the body compensates through Kussmaul respirations to blow off CO2 and shifts potassium into the extracellular fluid, causing hyperkalemia. Systemic acidosis leads to vasodilation, resulting in warm and flushed skin, while low pH suppresses the central nervous system, causing lethargy or confusion. Nurses should monitor these respiratory, electrolyte, and neurological changes closely.