— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病人表現出嚴重的上腹痛，哪項護理措施是最高優先級？
A client with acute pancreatitis presents with severe epigastric pain. Which nursing intervention is the highest priority?
- AAdminister IV analgesics給予靜脈止痛藥
- BAssess bowel sounds評估腸鳴音
- CMaintain NPO status✓ 正解維持禁食狀態
- DMonitor blood glucose levels監測血糖水平
— Explanation · 中文詳解 —
急性胰臟炎（Acute Pancreatitis）的核心病理在於胰臟酵素過早活化，導致胰臟組織自我消化。護理介入的首要目標是讓胰臟「休息」，以抑制胰液分泌並緩解疼痛。禁食（NPO）是減輕胰臟刺激最直接且有效的手段。在臨床決策中，我們必須優先處理病灶誘發因素，止痛藥與血糖監測雖為常規護理，但若持續進食導致胰液分泌，疼痛將難以緩解，併發症風險亦會大幅提升。
Maintaining NPO status is the highest priority because it rests the pancreas and inhibits the secretion of digestive enzymes that cause autodigestion and pain. While analgesics and monitoring are important, they are secondary to removing the physiological stimulus that triggers the inflammatory process and exacerbates the condition.