— 生理適應 · MEDIUM · MCQ —
一位病人因低血鉀入院，護理師應優先評估下列何種徵象？
A client is admitted with hypokalemia. Which finding should the nurse recognize as a priority assessment?
- AGeneralized fatigue全身性疲倦
- BPresence of irregular pulse✓ 正解心律不整的存在
- CPresence of muscle cramps肌肉痙攣的存在
- DDecreased bowel sounds腸鳴音減弱
— Explanation · 中文詳解 —
低血鉀（Hypokalemia）會影響細胞膜電位，導致心肌細胞興奮性異常，是臨床上危及生命的最主要風險。雖然肌肉無力、痙攣或腸蠕動減慢均為低血鉀的常見臨床徵象，但心臟傳導系統的改變（如心律不整）直接威脅病人的生命安全。依據 ABC（Airway, Breathing, Circulation）優先順序原則，循環系統的穩定性始終是護理評估的首要重點。
Hypokalemia causes cardiac electrical instability, making the presence of an irregular pulse the highest priority finding due to the risk of life-threatening dysrhythmias. While fatigue and muscle cramps are common, circulatory stability takes precedence over other symptoms.