— 生理適應 · MEDIUM · MCQ —
一名第一型糖尿病病人血糖值為 450 mg/dL，且呼吸有水果味。護理師應優先評估下列何種發現？
A client with type 1 diabetes mellitus presents with a blood glucose level of 450 mg/dL and a fruity breath odor. Which assessment finding should the nurse prioritize?
- APresence of deep, rapid respirations深而快的呼吸是否存在
- BPeripheral pulse strength周邊脈搏強度
- CSkin turgor and capillary refill皮膚張力與毛細血管再充盈時間
- DClient's current state of consciousness✓ 正解病人當前的意識狀態
— Explanation · 中文詳解 —
此病人表現出糖尿病酮酸中毒（DKA）的典型症狀：高血糖、水果味呼吸（酮體產生）與深快呼吸（庫斯莫耳呼吸，Kussmaul respirations，為補償代謝性酸中毒）。在 ABC 原則中，意識狀態（Neurological status）是評估病情嚴重度與腦部灌流的核心。意識改變可能預示病情已進展至嚴重階段，具有生命威脅。
In a client with diabetic ketoacidosis, the nurse should prioritize assessing the level of consciousness, as it reflects cerebral perfusion and disease severity. Changes in mental status indicate potential progression to coma and require immediate intervention to prevent life-threatening complications.