— 生理適應 · MEDIUM · MCQ —
一位第一型糖尿病病人血糖值為 450 mg/dL。護理師評估時應優先關注哪項臨床發現？
A client with type 1 diabetes mellitus presents with a blood glucose level of 450 mg/dL. Which clinical finding should the nurse prioritize during the assessment?
- ADifficulty with fine motor skills精細動作困難
- BReport of severe hunger主訴嚴重飢餓感
- CPresence of diaphoresis存在盜汗
- DPresence of deep, rapid respirations✓ 正解存在深而快的呼吸
— Explanation · 中文詳解 —
第一型糖尿病病人若血糖高達 450 mg/dL，極可能發展為糖尿病酮酸中毒（DKA）。深快呼吸（Kussmaul breathing）是身體試圖透過深呼吸排除過多的二氧化碳，以代償代謝性酸中毒的表現。這是 DKA 的典型臨床徵象，代表病人的代謝狀態已進入危急階段，需優先關注以進行後續的液體補充與胰島素治療。
A blood glucose level of 450 mg/dL in a client with type 1 diabetes suggests diabetic ketoacidosis (DKA), which causes metabolic acidosis. Deep, rapid respirations (Kussmaul breathing) are a compensatory mechanism to blow off carbon dioxide and correct the acid-base imbalance. This finding indicates a critical metabolic state requiring immediate intervention.