— 生理適應 · MEDIUM · MCQ —
護理師監測一位低血鉀病人，下列哪項評估發現最令人擔憂？
A nurse is monitoring a client with hypokalemia. Which assessment finding is most concerning?
- APresence of U waves on the ECG心電圖上出現 U 波
- BMuscle weakness in the lower extremities下肢肌肉無力
- CIrregular heart rhythm on the cardiac monitor✓ 正解心臟監護儀上顯示心律不整
- DDecreased bowel sounds腸鳴音減弱
— Explanation · 中文詳解 —
低血鉀影響細胞膜電位，最嚴重的危險在於心肌細胞興奮性改變，導致致命性心律不整。雖然腿部無力、腸蠕動減慢與 U 波均為低血鉀常見特徵，但心律不整直接威脅生命安全，屬於 Physiological Adaptation 中的首要緊急指標。
Hypokalemia affects cell membrane potentials, with the most critical risk being life-threatening cardiac arrhythmias. Although muscle weakness, decreased bowel sounds, and U waves on the ECG are common indicators of low potassium, an irregular heart rhythm poses the most immediate threat to physiological stability and requires urgent nursing attention.
✦ 台美臨床差異
美國護理師對心律異常的辨識與處置權限較高，台灣常需請醫師確認後給予抗心律不整藥物。