— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病人出現嚴重腹痛與噁心，護理師發現其鈣離子為 7.2 mg/dL。護理師應評估哪一項徵象？
A client with acute pancreatitis presents with severe abdominal pain and nausea. The nurse notes the client's calcium level is 7.2 mg/dL. Which sign should the nurse assess for?
- ATrousseau's sign✓ 正解Trousseau 徵象
- BMurphy's signMurphy 徵象
- CBabinski's signBabinski 徵象
- DHoman's signHoman 徵象
— Explanation · 中文詳解 —
低血鈣（< 8.5 mg/dL）在急性胰臟炎中常見，因脂肪壞死與鈣離子結合。Trousseau 徵象為評估神經肌肉過度興奮的關鍵指標，藉由充氣血壓計袖帶引起腕痙攣來偵測。其他選項：Homan 為 DVT，Babinski 為神經損傷，Murphy 為膽囊炎。
Acute pancreatitis often causes hypocalcemia due to saponification of fats binding calcium ions, leading to neuromuscular irritability. The nurse should assess for Trousseau's sign, which indicates latent tetany, while recognizing that Murphy's, Babinski's, and Homan's signs relate to gallbladder disease, neurological lesions, and deep vein thrombosis, respectively.
✦ 台美臨床差異
台美臨床皆重視電解質監測。美國護理師常執行 Trousseau 評估，台灣護理師亦熟練，惟台灣傾向依醫囑抽血後由醫師判讀與處置。