— 生理適應 · MEDIUM · SATA —
病人因糖尿病酮酸中毒（DKA）入院，護理師應預期看到哪些臨床表現？（選所有適合的）
A client is admitted with diabetic ketoacidosis (DKA). Which clinical findings should the nurse expect? (Select all that apply.)
- AKussmaul respirations✓ 正解庫斯莫爾氏呼吸
- BFruity breath odor✓ 正解水果味口氣
- CHypoglycemia低血糖
- DMetabolic alkalosis代謝性鹼中毒
- ESerum glucose > 250 mg/dL✓ 正解血清葡萄糖 > 250 mg/dL
— Explanation · 中文詳解 —
DKA 病人因酸中毒會出現補償性的庫斯莫爾呼吸（深快呼吸），呼出氣體帶有酮體產生的水果味。由於體內缺乏胰島素，血糖會顯著升高。DKA 的特徵為代謝性酸中毒（而非鹼中毒），且血糖遠高於正常值，而非低血糖。
Diabetic ketoacidosis (DKA) is characterized by hyperglycemia, typically with serum glucose levels exceeding 250 mg/dL, due to insulin deficiency. The body attempts to compensate for metabolic acidosis through Kussmaul respirations, and the accumulation of ketones results in a fruity breath odor. DKA presents with metabolic acidosis rather than alkalosis, and hypoglycemia is not a feature of this condition.
✦ 台美臨床差異
美國護理師常執行床邊血糖監測並依據胰島素滴定表（Sliding scale）調整，台灣醫院亦同，但重視危急值回報流程。