— 生理適應 · MEDIUM · MCQ —
一位急性胰臟炎病人正接受靜脈輸液並禁食，下列哪項評估結果是護理師需優先回報醫師的最高優先級？
A client with acute pancreatitis is receiving IV fluids and is NPO. Which assessment finding is the highest priority for the nurse to report to the healthcare provider?
- ASerum calcium level of 7.2 mg/dL✓ 正解血清鈣濃度為 7.2 mg/dL
- BAbsent bowel sounds in all four quadrants四個象限均無腸鳴音
- CReports of 6/10 abdominal pain主訴腹部疼痛程度為 6/10
- DBlood glucose of 180 mg/dL血糖值為 180 mg/dL
— 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。低血鈣（< 8.5 mg/dL）會引起神經肌肉興奮性增加，出現 Chvostek 徵象或 Trousseau 徵象，嚴重時甚至引發喉頭痙攣或心律不整，威脅病人生命安全，為需優先處理之急症。
Hypocalcemia is a serious complication of acute pancreatitis due to fat saponification binding calcium ions, which can lead to tetany and cardiac arrhythmias. This finding requires immediate reporting and intervention to prevent life-threatening neuromuscular and cardiac complications.
✦ 台美臨床差異
美國護理師常有獨立給予鈣補充之 protocol，台灣則多需醫師評估後開立醫囑。