— 生理適應 · HARD · MCQ —
一位診斷為嗜鉻細胞瘤（Pheochromocytoma）的病人。護理師應優先注意哪項評估以防止高血壓危象？
A client is diagnosed with Pheochromocytoma. Which assessment should the nurse prioritize to prevent a hypertensive crisis?
- AAvoidance of abdominal palpation✓ 正解避免腹部觸診
- BMonitoring blood glucose levels監測血糖水平
- CEvaluation of daily urine output評估每日尿液排出量
- DAssessing for peripheral edema評估周邊水腫
— Explanation · 中文詳解 —
嗜鉻細胞瘤位於腎上腺，會分泌大量兒茶酚胺。觸碰或按壓腹部（觸診）可能會刺激腫瘤，導致大量激素釋放，引發致命的高血壓危象。監測血糖（B）雖重要但非預防危機的首要操作；水腫（D）非此病主徵；尿量（C）為一般評估。
Nurses must avoid palpating the abdomen of a client with pheochromocytoma, as mechanical pressure on the tumor can trigger the release of catecholamines. This sudden surge can precipitate a life-threatening hypertensive crisis, making avoidance of abdominal manipulation a critical safety priority.
✦ 台美臨床差異
美國 NCLEX 非常重視此類「安全性操作禁忌」；台灣臨床教學亦會提到，但實際查房時需特別提醒學生不可誤觸。