— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病人正接受點滴輸液且禁食，下列何種評估結果是護理師需優先回報的？
A client with acute pancreatitis is receiving IV fluids and is NPO. Which assessment finding is the priority for the nurse to report?
- ASerum lipase level elevated血清脂肪酶濃度升高
- BTrousseau sign positive✓ 正解Trousseau 徵象陽性
- CAbsent bowel sounds腸鳴音消失
- DAbdominal guarding腹部防衛性緊張
— Explanation · 中文詳解 —
急性胰臟炎常因脂肪壞死與鈣離子結合，導致低血鈣。Trousseau 徵象陽性代表嚴重的低血鈣，可能引發心律不整或喉頭痙攣，具生命危險。B 為預期診斷數值；C 為胰臟炎常見體徵；D 為發炎引起的疼痛表現，皆不如低血鈣導致的 neuromuscular irritability 緊急。
Trousseau sign indicates hypocalcemia, a serious complication of acute pancreatitis caused by fat necrosis binding calcium. This condition can lead to life-threatening tetany and cardiac arrhythmias, making it the priority finding to report over expected symptoms like elevated lipase or abdominal guarding.
✦ 台美臨床差異
美護理師需評估並監測 Trousseau sign；台灣臨床較仰賴抽血數值確認低血鈣後再介入。