— 降低風險 · HARD · SATA —
護理師評估急性胰臟炎病人，哪些發現需立即回報醫師？（選所有適合的）
A nurse is assessing a client with acute pancreatitis. Which finding should be reported to the provider immediately? (Select all that apply.)
- ABlood glucose 210 mg/dL✓ 正解血糖 210 mg/dL
- BPresence of Cullen's sign✓ 正解出現卡倫氏徵象（Cullen's sign）
- CSerum lipase 450 U/L血清脂肪酶 450 U/L
- DDecreased bowel sounds腸音減弱
- EHypocalcemia (Chvostek sign positive)✓ 正解低血鈣（Chvostek 徵象陽性）
— Explanation · 中文詳解 —
急性胰臟炎會造成胰臟組織自我消化，進而引發全身性發炎與代謝紊亂。高血糖可能因胰島細胞受損而發生；Cullen's sign（腹部周圍皮下出血）提示嚴重的出血性胰臟炎；低血鈣則是因脂肪壞死消耗鈣離子所致，若出現 Chvostek sign（面神經叩擊反應），代表嚴重的低血鈣，隨時可能引發抽搐或心律不整。
Hyperglycemia suggests pancreatic endocrine dysfunction, while Cullen's sign indicates potentially fatal retroperitoneal hemorrhage. Positive Chvostek sign reveals severe hypocalcemia, which poses an immediate risk for tetany and cardiac arrhythmias requiring urgent intervention.