— 生理適應 · MEDIUM · MCQ —
一位糖尿病酮酸中毒（DKA）病人入院。護理師應優先評估下列哪項？
A client is admitted with diabetic ketoacidosis (DKA). Which assessment finding should the nurse prioritize?
- ABlood glucose level血糖值
- BUrine output尿量
- CSerum potassium level血清鉀離子濃度
- DLevel of consciousness✓ 正解意識水準
— Explanation · 中文詳解 —
糖尿病酮酸中毒（DKA）是一種急性代謝性危急狀況，臨床評估必須依循 ABC（Airway, Breathing, Circulation）與意識狀態（Neurological status）來決定優先級。意識狀態的改變不僅反映代謝性酸中毒的嚴重程度，也暗示腦水腫（Cerebral edema）的風險，這是 DKA 病人最致命的併發症之一，故應優先評估。
In diabetic ketoacidosis, the level of consciousness is the priority assessment finding because it reflects the severity of acidosis and the risk of cerebral edema, a life-threatening complication. While blood glucose, urine output, and serum potassium are important, neurological status takes precedence as it indicates immediate threats to brain function and airway protection.