— 生理適應 · EASY · MCQ —
一位急性胰臟炎病人禁食並接受點滴治療。下列哪項評估結果需要護理師立即介入？
A client with acute pancreatitis is NPO and receiving IV fluids. Which assessment finding requires the nurse's immediate intervention?
- APain rated 6 out of 10 on a numeric scale在數字量表上疼痛評分為6分
- BAbsent bowel sounds in all four quadrants四個象限均無腸鳴音
- CSerum amylase level of 500 U/L血清澱粉酶濃度為500 U/L
- DRigid, board-like abdomen✓ 正解腹部僵硬如木板
— Explanation · 中文詳解 —
急性胰臟炎病人若出現腹部僵硬如木板（Rigid, board-like abdomen），通常提示腹膜炎或腸穿孔，屬於腹部急症，需優先處理。腸音消失是胰臟炎常見症狀；血清澱粉酶升高是診斷指標；疼痛需給藥，但皆不及腹膜炎致命。
A PTT result three times the control value indicates excessive anticoagulation and a high risk of hemorrhage. The priority nursing action is to stop the heparin infusion immediately to prevent further anticoagulation and notify the healthcare provider for further evaluation and management.
✦ 台美臨床差異
美台臨床皆視板狀腹為緊急警訊，美國護理師常依協定啟動快速反應小組，台灣則多依醫師醫囑執行緊急檢查。