— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病人正接受靜脈輸液並禁食（NPO）。下列哪項評估發現是護理師需優先回報給醫師的？
A client with acute pancreatitis is receiving IV fluids and remains NPO. Which assessment finding is the priority for the nurse to report to the provider?
- ABlood glucose of 145 mg/dL血糖 145 mg/dL
- BPain level of 5 out of 10疼痛程度為 10 分中的 5 分
- CTrousseau's sign positive✓ 正解Trousseau 徵象陽性
- DAbsent bowel sounds in all four quadrants四個象限均無腸鳴音
— Explanation · 中文詳解 —
急性胰臟炎常因脂肪壞死及鈣離子沉積導致低血鈣，Trousseau's sign 陽性顯示神經肌肉過度興奮。低血鈣可能引發嚴重心律不整或痙攣，屬於生命徵象變化的潛在風險，較其他非特異性症狀更需優先處理。
A positive Trousseau's sign indicates hypocalcemia, a serious complication of acute pancreatitis caused by fat saponification. This finding requires immediate reporting as it signals potential life-threatening neuromuscular irritability and cardiac arrhythmias.
✦ 台美臨床差異
美國護理師常需評估並監測低血鈣跡象，台灣臨床則更依賴抽血數值確認。