— 生理適應 · HARD · MCQ —
護理師照護一位腸阻塞病患。哪項發現需要立即通知外科醫師？
A nurse is caring for a client with a bowel obstruction. Which finding would necessitate immediate notification of the surgeon?
- AHigh-pitched bowel sounds高頻腸鳴音
- BNausea and vomiting噁心與嘔吐
- CRigid, board-like abdomen✓ 正解僵硬如木板般的腹部
- DVisible peristaltic waves可見的蠕動波
— Explanation · 中文詳解 —
腸阻塞若演變成腹膜炎（Peritonitis），會出現腹部僵硬如板狀（Board-like abdomen），這是穿孔或絞窄性阻塞的危急徵兆。A 與 D 是腸阻塞的典型過程，B 是症狀之一，均需處理但 C 具有致命風險，代表進入腹膜炎階段。
A rigid, board-like abdomen indicates peritonitis, which is a surgical emergency often resulting from bowel perforation or strangulation. While high-pitched bowel sounds, nausea, and visible peristaltic waves are expected findings in bowel obstruction, they do not require immediate surgical intervention like peritonitis does.
✦ 台美臨床差異
在美國，這類評估異常會啟動 Sepsis protocol，台灣則更仰賴護理師的觀察與醫師對手術時機的評估。