— 生理適應 · MEDIUM · MCQ —
護理師照護一位疑似高血鉀的病人。哪項評估發現最令人擔憂？
A nurse is caring for a client with suspected hyperkalemia. Which assessment finding is most concerning?
- AMuscle weakness肌肉無力
- BPeaked T waves on ECG✓ 正解心電圖呈現尖峰T波
- CDiarrhea腹瀉
- DNausea噁心
— Explanation · 中文詳解 —
高血鉀會影響心臟的電生理活動，導致 ECG 異常。尖峰 T 波 (peaked T waves) 是高血鉀早期且危險的 ECG 變化，可能預示致命性的心律不整。雖然肌無力、噁心和腹瀉也可能發生，但 ECG 變化是直接的心臟影響。
Hyperkalemia significantly affects cardiac electrophysiology, making electrocardiogram (ECG) changes the most critical assessment finding. Peaked T waves are a classic early sign of hyperkalemia that indicate a high risk for fatal arrhythmias and cardiac arrest. Although muscle weakness and gastrointestinal symptoms may occur, they are less immediately life-threatening than potential cardiac complications.
✦ 台美臨床差異
美國心臟科和腎臟科團隊共同監測高血鉀病人，並使用 ECG 監測；台灣則依賴臨床判斷和實驗室結果，護理師需熟悉 ECG 判讀。