— 生理適應 · HARD · MCQ —
一名急性胰臟炎病人禁食並接受靜脈輸液。護理師檢查發現 Trousseau's sign 陽性。護理師應優先採取哪項行動？
A client with acute pancreatitis is NPO and receiving IV fluids. The nurse assesses the client and notes a positive Trousseau's sign. Which action should the nurse take first?
- APlace the client on seizure precautions將病人置於防癲癇發作 precautions
- BPerform a Chvostek's sign assessment進行Chvostek徵象評估
- CObtain an order for serum calcium levels✓ 正解取得血清鈣濃度的醫囑
- DAdminister IV calcium gluconate per standing orders依常規醫囑給予靜脈注射葡萄糖酸鈣
— Explanation · 中文詳解 —
Trousseau's sign 是低血鈣的特徵。急性胰臟炎中脂肪壞死會結合鈣離子導致低血鈣。護理師應先確認實驗室數據再給藥。雖然 Seizure precautions 很重要，但臨床判斷需先以診斷為基礎，再採取後續的藥物介入與安全預防措施。
Trousseau's sign indicates hypocalcemia, a common complication of acute pancreatitis due to fat saponification binding calcium. The nurse's priority action is to obtain an order for serum calcium levels to confirm the diagnosis before administering interventions or implementing safety precautions.
✦ 台美臨床差異
美國護理師常有權根據評估結果要求緊急採血；台灣臨床常需先確認醫囑或聯絡主治醫師才能抽血。