— 生理適應 · EASY · MCQ —
一位病患疑診為糖尿病酮酸中毒（DKA）。護理師應預期觀察到何種臨床表現？
A client is admitted with suspected diabetic ketoacidosis (DKA). Which clinical manifestation should the nurse expect to observe?
- AMoist, clammy skin皮膚潮濕、冰冷
- BWeight gain體重增加
- CDeep, rapid respirations✓ 正解深而快的呼吸
- DBradycardia心搏過緩
— Explanation · 中文詳解 —
DKA 導致代謝性酸中毒，身體為了補償酸鹼失衡，會透過呼吸系統增加排碳，引發深而快的庫斯莫呼吸（Kussmaul breathing）。此病患因滲透性利尿會脫水，皮膚應為乾燥，心率通常會因脫水而代償性增加（心搏過速），且伴隨體重減輕。
Diabetic ketoacidosis causes metabolic acidosis, prompting the body to compensate via the respiratory system by increasing carbon dioxide excretion, which results in deep, rapid Kussmaul respirations. Dehydration from osmotic diuresis leads to dry skin rather than moist or clammy skin, tachycardia instead of bradycardia, and weight loss due to fluid loss.
✦ 台美臨床差異
在美國，這類處置依賴護理師的評估與檢驗數據連動，台灣則高度依賴醫囑進行治療調整。