— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病人的血清鈣濃度為 7.2 mg/dL。護理師應優先評估下列哪項發現？
A client with acute pancreatitis presents with a serum calcium level of 7.2 mg/dL. Which nursing assessment finding should the nurse prioritize?
- AHyperactive bowel sounds腸鳴音亢進
- BIncreased urinary output尿液排出量增加
- CFlattened T waves on ECG心電圖上 T 波平坦
- DPositive Trousseau's sign✓ 正解特魯索氏徵象（Trousseau's sign）陽性
— Explanation · 中文詳解 —
低血鈣（正常值 8.5-10.5 mg/dL）會導致神經肌肉興奮性增加，引發手足搐搦症（Tetany）。Trousseau's sign 是評估低血鈣最常用的指標之一。其他選項中，腸鳴音增加較少見，低血鈣通常導致 QT 間期延長而非 T 波平坦（後者為低血鉀），尿量變化與低血鈣無直接關聯。
Hypocalcemia causes increased neuromuscular excitability, making Trousseau's sign a priority assessment finding to detect tetany. While hypocalcemia typically prolongs the QT interval on an ECG, flattened T waves are associated with hypokalemia. Hyperactive bowel sounds and changes in urinary output are not primary indicators of low serum calcium levels.
✦ 台美臨床差異
美國護理師常執行 Trousseau's sign 檢查；台灣臨床護理師亦熟知此技術，但診斷執行權限嚴格劃歸醫療人員。