— 生理適應 · HARD · MCQ —
在肝硬化病人身上，哪項評估發現是護理師應優先報告的？
Which assessment finding would be a priority for the nurse to report in a client with cirrhosis of the liver?
- ADark-colored urine深色尿液
- BA change in level of consciousness✓ 正解意識水準改變
- CPresence of spider angiomas出現蜘蛛痣
- DMild peripheral edema輕度周邊水腫
— Explanation · 中文詳解 —
肝硬化病人意識狀態改變（如嗜睡、混亂）是肝性腦病變（Hepatic Encephalopathy）的早期徵兆，起因於血液中氨濃度升高，若不即時處置會進展為昏迷甚至死亡。蜘蛛痣、水腫與尿液變深皆為肝硬化的慢性徵象，優先級較低。
A change in level of consciousness is a priority finding in clients with cirrhosis as it may indicate hepatic encephalopathy due to elevated ammonia levels. This condition can rapidly progress to coma and death if not treated immediately, unlike chronic signs such as spider angiomas or mild edema.
✦ 台美臨床差異
美國護理師在意識變化時會優先評估氨數值與執行神經學檢查，台灣護理師亦同，皆視此為重大警訊。