— 生理適應 · HARD · MCQ —
一位急性胰臟炎病患正在禁食。下列哪項評估發現需要立即通知醫師？
A client with acute pancreatitis is NPO. Which assessment finding requires immediate notification of the provider?
- ABlood glucose level of 145 mg/dL血糖值 145 mg/dL
- BHypoactive bowel sounds in all four quadrants四個象限腸蠕動音減弱
- CAbdominal guarding and rigidity✓ 正解腹部保護性收縮與僵硬
- DReports of 4/10 epigastric pain主訴上腹部疼痛 4/10
— Explanation · 中文詳解 —
急性胰臟炎若出現腹部僵硬 (Rigidity) 與反彈痛 (Guarding)，強烈提示腹膜炎 (Peritonitis) 的發生，這可能是胰臟壞死或穿孔導致的緊急併發症。B 為胰臟炎常見臨床表徵，D 為預期之疼痛表現，A 雖高但未達極端異常，C 選項顯示腹腔內災難性變化，需優先介入。
Abdominal guarding and rigidity are critical findings that suggest peritonitis, a life-threatening complication of acute pancreatitis potentially caused by necrosis or perforation. While mild hyperglycemia, hypoactive bowel sounds, and moderate pain are expected manifestations, signs of peritoneal irritation require immediate provider notification.
✦ 台美臨床差異
台美對急性胰臟炎的護理重點一致，差異在於美國護理師常需更主動依據臨床指標啟動外科會診。