— 生理適應 · HARD · MCQ —
一名急性胰臟炎病人血鈣值為 7.2 mg/dL。護理師在評估時應優先檢查哪項身體徵象？
A client with acute pancreatitis presents with a serum calcium level of 7.2 mg/dL. Which physical assessment finding should the nurse prioritize during the examination?
- ABabinski's sign巴賓斯基氏徵象（Babinski's sign）
- BTrousseau's sign✓ 正解特魯索氏徵象（Trousseau's sign）
- CMurphy's sign墨菲氏徵象（Murphy's sign）
- DHoman's sign霍曼氏徵象（Homan's sign）
— Explanation · 中文詳解 —
低血鈣（< 8.5 mg/dL）會導致神經肌肉興奮性增加，出現手足搐搦。Trousseau's sign 是檢測潛在性低血鈣的特徵性徵象，即壓迫上臂血壓計袖帶引起的手部痙攣。胰臟炎病人因脂肪壞死常併發低血鈣，需密切監測抽搐風險。
Acute pancreatitis can cause hypocalcemia due to fat saponification, leading to increased neuromuscular irritability. The nurse should prioritize assessing for Trousseau's sign, which involves carpal spasm induced by inflating a blood pressure cuff, as it is a specific indicator of latent tetany associated with low serum calcium levels.
✦ 台美臨床差異
台美臨床對於 Trousseau's sign 的誘發技術一致，但護理師在美國更強調自主執行並評估預防跌倒措施。