— 生理適應 · EASY · MCQ —
病人因糖尿病酮酸中毒（DKA）入院，護理師應預期出現何種臨床表現？
A client is admitted with diabetic ketoacidosis (DKA). Which clinical manifestation should the nurse expect?
- ADeep, rapid breathing✓ 正解深而快的呼吸
- BHypertension高血壓
- CWeight gain體重增加
- DBradycardia心搏過緩
— Explanation · 中文詳解 —
糖尿病酮酸中毒時，體內因酸中毒導致代償機制啟動，透過庫斯莫呼吸（Kussmaul breathing）呼出過多的二氧化碳以調節 pH 值。此過程表現為深快呼吸。DKA 常見脫水引起的低血壓與心搏過速，體重則因嚴重的液體流失而下降。
Clients with diabetic ketoacidosis (DKA) typically exhibit Kussmaul respirations, characterized by deep and rapid breathing, as a compensatory mechanism to blow off carbon dioxide and correct metabolic acidosis. Other expected findings include hypotension and tachycardia due to severe dehydration, rather than hypertension, weight gain, or bradycardia.
✦ 台美臨床差異
兩地針對 DKA 的護理規範均強調輸液監測與電解質補充，台灣臨床更重視護理師在第一線回報血糖與酸鹼值變化之準確性。