— 生理適應 · MEDIUM · MCQ —
一位腸阻塞病人。護理師應預期哪項臨床表現？
A nurse is caring for a client with a bowel obstruction. Which clinical manifestation should the nurse anticipate?
- AHigh-pitched bowel sounds proximal to the obstruction✓ 正解阻塞處近端的高頻腸鳴音
- BSteady, localized abdominal pain持續且局部的腹痛
- CWeight gain due to fluid retention因水分滯留而體重增加
- DFrequent, loose, watery stools頻繁、稀爛的水樣便
— Explanation · 中文詳解 —
腸阻塞時，為了推動阻塞處前方的腸內容物，腸蠕動會代償性增強，產生高頻金屬音（high-pitched sounds）。隨後若腸道失去活力，則會變成無腸音。腹瀉與體重增加非阻塞特徵；疼痛通常為陣發性絞痛，而非單純局部壓痛。
Hyperactive, high-pitched bowel sounds are expected proximal to the obstruction as the intestines attempt to push contents past the blockage. Pain is typically cramping and intermittent rather than steady, and obstipation, not diarrhea, is the usual presentation.
✦ 台美臨床差異
美台皆採 NG tube 減壓與禁食治療，若無效則進入手術評估，護理重點一致。