護理師評估一位急性胰臟炎病人。下列哪項體徵最能顯示病人存在後腹腔出血？
A nurse is assessing a client with acute pancreatitis. Which physical finding would most likely indicate the presence of retroperitoneal hemorrhage?
- ARebound tenderness in the right upper quadrant右上腹反彈痛
- BAbsence of bowel sounds in all quadrants各象限腸音消失
- CPain that radiates to the left shoulder疼痛放射至左肩
- DBluish discoloration around the umbilicus✓ 正解臍周出現藍紫色色素沉澱
急性胰臟炎若進展為壞死出血性，胰酵素會消化周圍血管導致出血。當血液從後腹腔沿著組織間隙滲透到前腹壁時，會出現特定的瘀斑。臍周的青紫瘀斑稱為 Cullen's sign，而腰部肋腹側的瘀斑則稱為 Grey Turner's sign。這些徵象是病情危急的紅旗指標，預示著可能發生低血容性休克。護理師應立即評估生命徵象並準備輸液復甦。選項 A 多見於膽囊炎。選項 C 是 Kehr's sign，與脾臟破裂相關。選項 B 則是麻痺性腸阻塞的表現，雖可見於胰臟炎但非出血特異指標。
Cullen’s sign, characterized by periumbilical bruising, indicates retroperitoneal hemorrhage where blood tracks through tissue planes to the anterior abdominal wall. This finding suggests severe acute pancreatitis with necrotizing complications and potential hypovolemic shock. Other options describe signs of different conditions, such as cholecystitis or splenic injury, which do not specifically indicate retroperitoneal bleeding.
在美國 NCLEX 考試中，Cullen's sign 和 Grey Turner's sign 是經典的高頻考點，要求護理師具備高度臨床警覺；在台灣臨床實務中，醫師通常會透過超音波或 CT 確認出血，護理師的身體評估發現多作為輔助參考而非診斷依據。