— 生理適應 · HARD · MCQ —
一名急性胰臟炎病人出現板狀腹及劇烈疼痛。下列哪項評估結果最令護理師擔憂？
A client with acute pancreatitis presents with a board-like abdomen and severe pain. Which assessment finding is most concerning to the nurse?
- ARespiratory rate 28 breaths/min with crackles✓ 正解呼吸頻率 28 次/分並伴有囉音
- BBlood pressure 100/60 mmHg血壓 100/60 mmHg
- CSerum amylase 400 U/L血清澱粉酶 400 U/L
- DHypoactive bowel sounds腸鳴音減弱
— Explanation · 中文詳解 —
急性胰臟炎併發症中，肺部併發症（如 ARDS）死亡率極高。呼吸急促合併肺部囉音提示肺水腫或肺泡塌陷，是全身性發炎反應徵兆。B 選項血壓尚可接受；B 為胰臟炎常見症狀；D 數值雖高但不代表病情惡化程度。
Respiratory distress with crackles suggests acute respiratory distress syndrome (ARDS), a life-threatening complication of acute pancreatitis caused by systemic inflammation, making it the most concerning finding compared to other symptoms.
✦ 台美臨床差異
美國護理師常需執行緊急血氧飽和度與呼吸形態監測；台灣對於 ARDS 預警多依賴醫師判讀。