— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病人禁食中並接受點滴，下列哪項評估結果需要護理師立即介入？
A client with acute pancreatitis is receiving IV fluids and remains NPO. Which assessment finding requires immediate nursing intervention?
- ASerum amylase 450 U/L血清澱粉酶 450 U/L
- BAbsent bowel sounds腸蠕動音消失
- CPain rated 6/10疼痛評分 6/10
- DTrousseau's sign positive✓ 正解Trousseau 氏徵象陽性
— Explanation · 中文詳解 —
急性胰臟炎常因脂肪壞死，脂肪酸與鈣離子結合形成皂化反應，導致低血鈣（Hypocalcemia）。低血鈣的臨床表徵包括 Chvostek's sign（面神經叩擊反射陽性）與 Trousseau's sign（手臂壓力袖帶加壓後手部抽搐）。嚴重低血鈣會引發喉頭痙攣或心律不整，這對於急性胰臟炎病人是立即性的生命威脅，必須優先處理。
A positive Trousseau's sign indicates hypocalcemia, a potential complication of acute pancreatitis caused by fat saponification binding calcium. Severe hypocalcemia can lead to life-threatening laryngospasm or cardiac arrhythmias, necessitating immediate nursing intervention.