— 生理適應 · EASY · MCQ —
一位急性胰臟炎病人出現嚴重腹痛、噁心和嘔吐。護理師應優先評估下列哪項發現？
A client with acute pancreatitis presents with severe abdominal pain, nausea, and vomiting. Which assessment finding is the priority for the nurse to evaluate?
- AAbdominal guarding and rigidity腹部防衛與強直
- BSerum lipase level of 500 U/L血清脂肪酶濃度 500 U/L
- CBlood pressure of 90/60 mmHg✓ 正解血壓 90/60 mmHg
- DHyperactive bowel sounds腸鳴音亢進
— Explanation · 中文詳解 —
急性胰臟炎病人常因嚴重噁心嘔吐導致體液丟失，加上組織發炎引起「第三空間」體液轉移，導致循環血量不足。低血壓（90/60 mmHg）暗示病人可能進入休克狀態，這會導致器官灌流不足與多重器官衰竭。在 ABC（Airway, Breathing, Circulation）原則下，循環穩定（Circulation）是優先評估與處理的事項。
Hypotension is the priority finding because it indicates potential hypovolemic shock resulting from third-spacing and fluid loss, which threatens organ perfusion. According to ABC principles, stabilizing circulation takes precedence over assessing diagnostic markers or localized pain symptoms.