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第四章 酸碱平衡紊乱

复习提要

一、机体对酸碱平衡的调节

(一)血液缓冲系统的调节作用
1. 四个主要缓冲对 NaHCO3/H2CO3 Na2HPO3/NaH2PO4 B 血浆蛋白/H 血浆蛋白 B 血红蛋白/H 血红蛋白
2.缓冲反应 HCL+NaHCO3→ H2CO3+NaCl (强酸) (弱酸) H2O+CO2 (肺呼出) NaOH+H2CO3 →NaHCO3+H2O (强碱) (弱碱) (肾排出) (二)组织细胞的调节作用 通过细胞膜内外H+—K+离子的交换实现 (三)肺的调节作用 H++HCO3- →H2CO3 →H2O+CO2 排出一个CO2,等于排出一个H+ (四)肾脏的调节作用

1.泌H+和重吸收NaHCO3

2.产NH3排NH4+

3.排出可滴定酸

二、反映血液酸碱平衡状态的指标和意义

(一)Henderson-Hasselbalch 方程式 1.方程式 : [BA] pH =Pka+log [HA] [HCO3-] =Pka+log [H2CO3] 24 =6.1+log 1.2 =6.1+1.301=7.401

2.意义

①血液pH值取决于NaHCO3和H2CO3的浓度比值
②血液内的H2CO3浓度受呼吸因素调节,NaHCO3浓度主要受肾脏的调节
③如果NaHCO3或H2CO3其中任何一项浓度发生改变,另一项通过代偿活动作相应增减,pH值仍在正常范围,为代偿性,反之,为失代偿性 (二)反映血液酸碱平衡的常用指标

1.H+浓度和PH值

H+浓度的负对数,即为PH值,正常人动脉血液的PH值为7.35~7.45。

2.二氧化碳分压(PaCO2)

①溶解在血浆中的CO2分子产生的压力或人动脉血PaCO2正常范围33~47mmHg反映呼吸因素的最佳指标
②PaCO247mmHg. ,表示肺通气不足 原发性呼吸性酸中毒 继发性代谢性碱中毒

3.缓冲碱(BB)

①血液中一切具有缓冲作用的碱性物质的总和正常范围45~55mmol/L 反映代谢性因素的指标
②BB>55mmol/ L为原发性代谢性碱中毒或继发性呼吸性酸中毒 BB3mmol/L原发性代谢性碱中毒或继发性呼吸性酸中毒 BD>3mmol/L原发性代谢性酸中毒或继发性呼吸性碱中毒

5.标准碳酸氢盐(SB)与实际碳酸氢盐(AB)

①SB是血标本指标准条件下,测得的血浆HCO3-的浓度,判断代谢性因素的指标,正常值为22~27mmol/L SB>27mmol/L原发性代谢性碱中毒或继发性呼吸性酸中毒 SBSB指示CO2潴留,见于原发性呼吸性酸中毒及继发性代谢性碱中毒 ABSB

4.对机体的影响

①中枢神经系统功能紊乱:烦燥不安,精神错乱。 ②对神经肌肉的影响:手足抽搦,面部和肢体肌肉抽动。 ③低钾血症:心律失常。

5.防治原则

①积极防治原发病 ②合理选用药物纠正碱中毒 (二)呼吸性碱中毒 血浆H2CO3浓度原发性降低

1.原因和机制

①精神性过度通气
②乏氧性缺氧
③机体代谢亢进
④人工呼吸过度

2.机体代偿调节

①细胞内外离子交换和细胞内液缓冲
②肾脏代偿调节(与代谢性碱中毒一致)

3.血气分析

过度通气PaCO2降低,AB减少,ABSB能有: A.代谢性酸中毒 B.呼吸性酸中毒 C.呼吸性碱中毒 D.代谢性碱中毒 E.混合性碱中毒 23. 对呼吸性H+的缓冲,主要靠:
A.HCO3-缓冲系统 B.HCO3-以外的缓冲系统
C.血浆蛋白缓冲系统 D.磷酸盐缓冲系统
E.其他缓冲系统
24.对代谢性H+的缓冲主要靠:
A.HCO3-缓冲系统 B.血浆蛋白缓冲系统
C.血红蛋白缓冲系统 D.磷酸盐缓冲系统
E.HbO2缓冲系统
25. 某慢性肺心病患者,血气分析及电解质测定结果如下:
PH 7.40 PaCO2 67mmHg, HCOI3- 40mmol/人 血Na+
140mmol/人CI- 90mmol/人诊患者的酸碱平衡诊断为HCO3-:
A.呼吸性酸中毒
B.代谢性碱中毒
C.代谢性酸中毒合并代谢性碱中毒
D.呼吸性酸中毒合并代谢性碱中毒
E.呼吸性碱中毒
26.某肺心病患者,血气分析及电解质测定结果如下:PH 7.26,PaCO2 85.8mmHg, HCO3- 37.8mmol/人 CI- 90mmol/人 Na+ 140mmol/人 下列诊断中最有可能是哪一种: A.呼吸性酸中毒 B.代谢性酸中毒 C.呼吸性酸中毒合并代谢性酸中毒 D.呼吸性酸中毒合并代谢性碱中毒 E.呼吸性碱中毒 27.肝功能异常并合并代谢性酸中毒患者,在纠正酸中毒时,不宜采用下列: 哪一种药物: A.0.9% NaCl B.1.5%NaHCO C.乳酸钠 D.三羟甲基氨基甲烷 E.氯化镁 28.代谢性酸中毒时,二氧化碳结合力为45~30%状态下,中枢神经系统 常出现: A.轻度的烦躁 B.萎糜 C.昏睡 D.昏迷 E.精神错乱 29.呼吸性酸中毒时,对中枢神经系统功能影响较大的因素是: A.氢离子浓度升高 B.r-氨基丁酸减少 C.PH下降 D.二氧化碳升高 E.高血钾 30.酸中毒时对机体影响危害最大的是: A.对中枢的抑制作用 B.对血管的扩张作用 C.高血钾对心肌细胞的毒性作用 D.低血钾对心肌细胞的毒性作用 E.溶骨作用 31.急性碱中毒时出现手足搐搦和四肢抽动的主要原因是: A.血清K+减少 B.血清Cl减少 C.血清Ca2+减少 D.血清Na+减少 E.血清Mg2+减少 32.下列指标中哪一项是反映酸碱平衡呼吸困难的最佳指标: A.pH B.PaCO C.SB D.AB 33. 低血钾引起的酸碱失衡紊乱的特点是:
___________________________________________________________
血浆HCO3- 血浆H+ 细胞内H+ 尿液H+
____________________________________________________________
A. ↓ ↑ ↑ ↑
B. ↓ ↑ ↓ ↓
C. ↑ ↓ ↓ ↓
D. ↑ ↓ ↑ ↑
E. ↓ ↑ ↑ ↑ _____________________________________________________________ 34. 血气分析测定结果为PaCO2降低,同时伴有HCO3-升高,可诊断为: A.呼吸性酸中毒
B.代谢性酸中毒
C.呼吸性碱中毒
D.代谢性碱中毒
E.呼吸性碱中毒合并代谢性碱中毒 35.碱中毒时血红蛋白氧离曲线呈现: A.右移 B.左移 C.先左移后右移 D.先右移后左移 E.不移动 36.慢性呼吸性酸中毒时机体主要代偿方式是: A.细胞外液缓冲 B.呼吸代偿 C.细胞内缓冲 D.肾脏代偿 E.骨骼代偿 37.呼吸性酸中毒合并代谢性酸中毒可见于: A.慢性肺心病患者长期服用利尿剂 B.水杨酸中毒 C.心跳呼吸聚停 D.革兰阴性杆菌败血症 E.幽门梗阻长时间进食少 38. 血液中pH值主要取决于血浆中:
A.CO2CP B.PaCO2 C.HCO3-
D.HCO3-与H2CO3的比值 E. H2CO3 39. 反映血浆中HCO3-实际量的指标是:
A.碳酸氢盐缓冲系统 B.磷酸盐缓冲系统
C.血红蛋白缓冲系统 D.氧合血红蛋白缓冲系统
E.其他缓冲系统
40.慢性呼吸性酸中毒时,机体代偿的主要方式: A.细胞外液缓冲 B.呼吸代偿 C.细胞内缓冲 D.肾脏代偿 E.血液系统的缓冲
41.某溺水窒息患者,经抢救后其血气分析结果为:PH 7.15 PaCO2 80mmHg,HCO3- 27mmol/L应诊断:
A.代谢性酸中毒 B.代谢性碱中毒
C.急性呼吸性酸中毒 D.慢性呼吸性酸中毒 E.呼吸性碱中毒 42. 碱中毒时出现神经肌肉应激性亢进,手足抽搐的主要原因是:
A.血清K+减少 B.血清CI- 减少 C.血清Ca2+减少
D.血清Na+减少 E.血清Mg2+减少 43.不同类型脱水的分型依据是: A.体液丢失的总量 B.电解质丢失的总量 C.细胞外液的总量 D.细胞外液的晶体渗透压 E.细胞外液的胶体渗透压 44. 血浆中含量最多的阴离子是:
A.HCO3- B.HPO42- C.SO42- D.CI- E.NO2 45.体内体液中各部分间渗透压关系是: A.细胞内高于细胞外 B.细胞内低于细胞外 C.血浆低于组织间液 D.组织间液低于细胞内液 E.细胞内外基本相等 46. 细胞内外渗透压的平衡主要靠哪一种物质的移动来维持:
A.Na+ B.K+ C.H20 D.葡萄糖 E.Ca2+ 47. 组织间液和血浆所含的溶质含量的主要差别是:
A.Na+ B.CI C.蛋白质 D.有机酸 E.Ca2+ 48. 决定细胞外液渗透压的主要因素是:
A.球蛋白 B.白蛋白 C.Na+ D.K+ E.Ca2+ 49.中度高渗性脱水患者的失水量相当于体重的: A.1~2% B.2~5% C.5~10% D.10~15% E.15%~20% 50.低渗性脱水时,下列描述哪项正确: A.细胞外液渗透压增高,容量降低 B.细胞内液渗透压增高,容量降低 C.细胞外液渗透压降低,容量降低 D.细胞内液渗透压降低,容量降低 E细胞内液渗透压不变,容量不变 51.高渗性脱水患者的处理原则是补充: A.5%葡萄糖液 B.0.9%NaCl液 C.先5%葡萄糖液后0.9%NaCl液 D.先3%NaCl液后5%葡萄糖液 E.同时给予5%葡萄糖液和3%NaCI液 52."失盐性肾炎"患者的肾脏内,哪一部位对钠重呼吸发生障碍: A.近曲小管 B.髓袢升支粗段 C.髓袢降支 D.远曲小管和集合管 E.髓袢升支细段 53.低渗性脱水患者体液丢失的特点是: A.细胞内液和外液均有明显丢失 B.细胞内液无丢失,仅丢失细胞外液 C.细胞内液无丢失,仅丢失血浆 D.细胞内液无丢失,仅丢失组织间液 E.细胞内液丢失,细胞外液无丢失 54.下列哪一种情况的早期出现精神神经症状: A.急性水中毒 B.高渗性脱水 C.低渗性脱水 D.等渗性脱水 55.急性低钾血症对神经肌肉组织中生理的影响是: _____________________________________________________________ 静息电位(负值) 阈电位 静息电与阈电位差值 _____________________________________________________________ A.↑ 不变 ↑ B.↓ 不变 ↓ C.↑ ↑ 不变 D.↓ ↓ 不变 E.↓ ↓ 不变 _____________________________________________________________ 56.急性低钾血症时心肌电生理特点是: ___________________________________________________________ 静息电位与阈电位差值 兴奋性 ___________________________________________________________ A. ↑ ↑ B. ↓ ↓ C. ↑ ↓ D. ↓ ↑ E. 不变 不变 __________________________________________________________ 57.低钾血症对心肌的影响是: ___________________________________________________________ 兴奋性 传导性 自律性 收缩性 ____________________________________________________________ A. ↑ ↑ ↑ ↑ B. ↓ ↑ ↑ ↑ C. ↑ ↓ ↑ ↑ D. ↑ ↑ ↓ ↑ E. ↓ ↓ ↓ ↓ _____________________________________________________________ 58.高钾血症对心肌的影响是: ____________________________________________________________ 兴奋性 传导性 自律性 收缩性 _____________________________________________________________ A. ↑→↓ ↓ ↓ ↓ B. ↓→↑ ↓ ↓ ↓ C. ↓ ↑ ↑ ↑ D. ↑ ↓ ↓ ↓ E. ↓ ↓ ↓ ↓ ____________________________________________________________ 59.神经肌肉应激性增强可见于: A.低血磷 B.低血钾 C.高血钙 D.低血镁 E.高血钾 60.下列哪种情况可产生低镁血症: A.甲状旁腺功能低下 B.甲状腺激素分泌过多 C.促性腺激素分泌过多 D.肾上腺功能减退 E.高血钾 61.AG增高反映发生了: A.高氯血性代谢性酸中毒 B.正常氯血性代谢性酸中毒 C.代谢性碱中毒 D.呼吸性酸中毒 E.呼吸性碱中毒 62.从动脉抽取血样后,如不与大气隔绝,下列哪一项指标将受影响: A.SB B.AB C.BE D.BB E.BD 63.急性代谢性酸中毒,最主要的代偿方式是: A.肾脏代偿 B.血液代偿 C.呼吸代偿 D.细胞外液缓冲 E.骨骼缓冲 64.某慢性肾功能不全患者,因上腹部不适呕吐而急诊入院,血气分析结果:PH 7.39 PaCO2 43.8mmHg HCO3- 26.6mmol/人 Na+ 142mmol/人 Cl- 96.5mmol/人诊断属哪一种酸碱失衡:
A.AG增高性代谢性酸中毒
B.AG正常性代谢性酸中毒
C.AG增高性代谢性酸中毒合并代谢性碱中毒
D.AG正常性代谢性酸中毒合并代谢性碱中毒
E.AG增高性代谢性酸中毒合并呼吸性酸中毒
65.下列疾病中哪一种不引起高输出量性心衰: A.甲状腺功能亢进症 B.贫血 C.心肌病 D.维生素B1缺乏 E.动-静脉瘘 66.常引起呼吸性酸中毒合并代谢性酸中毒的疾病是: A.严重的肝功能衰竭合并败血症 B.严重的慢性阻塞性肺病合并中毒性休克 C.糖尿病患者合并剧烈呕吐 D.剧烈呕吐伴有严重腹泻 E.严重高热 67.剧烈呕吐伴有严重腹泻的患者可引起的酸碱平衡紊乱类型为: A.代谢性酸中毒合并代谢性碱中毒 B.代谢性酸中毒合并呼呼性碱中毒 C.代谢性碱中毒合并呼吸性碱中毒 D.代谢性碱中毒 E.代谢性酸中毒 68.剧烈呕吐合并感染并有发热时,易引起: A.呼吸性碱中毒+代谢性酸中毒 B.代谢性碱中毒+呼吸性碱中毒 C.代谢性碱中毒+呼吸性酸中毒 D.呼吸性酸中毒+代谢性酸中毒 E.代谢性碱中毒+代谢性酸中毒 69.下列哪一项混合性酸碱失衡不可能出现: A.代谢性酸中毒合并代谢性碱中毒 B.呼吸性酸中毒合并呼吸性碱中毒 C.代谢性酸中毒合并呼吸性碱中毒 D.代谢性酸中毒合并呼吸性酸中毒 E.代谢性碱中毒合并呼吸性碱中毒 70. 对代谢性H+的缓冲主要依靠:
A.HCO-3缓冲系统 B.血浆蛋白缓冲系统
C.Hb缓冲系统 D.磷酸盐缓冲系统
E.HbO2缓冲系统
71. 机体新陈代谢时产生的挥发性酸是:
A.r-羟丁酸 B.H2CO3 C.H2SO4 D.尿酸 E.磷酸 72.肾脏产氨的主要部位是: A.远曲小管 B.近曲小管 C.集合管 D.髓袢 E.肾小球 73.关于PH值的描述,下列哪项是错误的: A.PH值代表[H+]的负对数 B.可由Henderson-Hasselbalch公式计算 C.PH值的变化不能区别代谢性或呼吸性酸碱平衡紊乱 D.PH值正常表明无酸碱平衡紊乱 E.PH值正常不排除有酸碱平衡紊乱 74.下述哪种情况不引起呼吸性碱中毒: A.大气氧分压过低 B.人工呼吸时过度通气 C.长时间在密闭小室中 D.癔病发作 E.革兰阴性杆菌败血症 75. 血液中具有最强缓冲能力的缓冲对是:
A.NaHCO3/H2CO3
B.Na2HPO4/NaH2PO4
C.Na-Pr/H-Hb
D.KHCO3/H2CO3
E.K-Hb/H-Hb
76.下列哪一项混合性酸碱失衡不可能出现: A.代谢性酸中毒合并代谢性碱中毒 B.呼吸性酸中毒合并呼吸性碱中毒 C.代谢性酸中毒合并呼吸性碱中毒 D.代谢性酸中毒合并呼吸性酸中毒 E.代谢性碱中毒合并呼吸性碱中毒 77. PaCO2升高至何种程度能使肺的通气量增加2倍:
A.PaCO2为5.32kPa
B.<5.32KPa
C.>5.32kPa
D.>8.3kPa
E. >9.0kPa 78.下列哪一种对血PH意义是错误的:
A.PH= -Log[H+]
B.PH= Log[H+]
C.PH= pka +Log[HCO-]/0.03×PCO2
D.PH= 6.1+Log[HCO-]/HCO]
E.PH= 6.1+Log[HCO-]/ a×PCO 79.对二氧化碳结合力的表述,下列哪一项是错误的: A.其正常范围是25~35mmol/L B.是指血浆中化学结合的二氧化碳量 C.以容积表示时正常值为50-70ml% D.可以反映血浆中碳酸氢钠的含量 E.正常血浆平均为27mmol/L 80.能反映血液中全部缓冲碱的指标是: A.AB B.PaCO C.SB D.BB E.BE 81.PaCO<4.39KPa(33mmHg)常提示: A.代谢性碱中毒 B.呼吸性碱中毒 C.呼吸性酸中毒 D.代谢性碱中毒合并呼吸性酸中毒 E.代谢性酸中毒合并呼吸性酸中毒 82.AG增高提示机体可发生: A.高氯血性代谢性酸中毒 B.正氯血性代谢性酸中毒 C.代谢性碱中毒 D.呼吸性酸中毒 E.呼吸性碱中毒 83.酸中毒时血钾的变化规律是: A.升高 B.不变 C.降低 D.先升后降 E.先降后升 84.严重的心力衰竭患者发生酸碱平衡紊乱的类型: A.乳酸增多的代谢性酸中毒 B.酮体增多的代谢性酸中毒 C.代谢性碱中毒 D.呼吸性酸中毒 E.呼吸性酸中毒合并代谢性碱中毒 85. 溃疡病并发幽门梗阻患者,因反复呕吐入院,血气分析结果如下: PH>7.48,PaCO26.4kPa(48mmHg),HCO-336mmol/L该病人酸碱失衡的
类型是:
A.代谢性酸中毒 B.代谢性碱中毒 C.呼吸性酸中毒
D.呼吸性碱中毒 E.混合性酸碱中毒 86. 氯摄入不足引起代谢性碱中毒的机制是:
A.H+经消化道丢失过多
B.H+—Na+交换加强致重吸收HCO3-
C.H+—Na+交换减少,致HCO重吸增加
D.H+—Na+交换减少,致HCO重吸收减少
E.H+—Na+交换无改变而致HCO重吸收增加
87.呼吸性碱中毒,经肾脏代偿调节后,血生化指标常为: A.AB.SB.BB和CO C P均正常,BE正常 B.AB.SB.BB和CO C P均升高,BE负值升高 C.AB.SB.BB和CO C P均下降,BE负值增大 D.AB.SB.BB和CO C P均下降,BE增大 E. AB.SB.BB和CO C P均正常,BE减小 88.饥饿引起的酸碱平衡紊乱属于: A.乳酸酸中毒 B.酮症酸中毒 C.呼吸性酸中毒 D.呼吸性碱中毒 E.代谢性碱中毒 89.严重腹泻常引起: A.代谢性酸中毒 B.代谢性碱中毒 C.AG正常高氯血性酸中毒 D.AG增大低氯性酸中毒 E.呼吸性酸中毒 90.阴离子间隙(AG)增高的代谢性酸中毒常见于: A.腹泻 B.使用乙酰唑胺利尿 C.糖尿病 D.肾小管性酸中毒 E.大量输入生理盐水 91.输入大量生理盐水引起: A.AG增大,高氯性酸中毒 B.AG正常,低氯性中毒 C.AG增大,低氯血性酸中毒 D.AG正常,高氯血性酸中毒 E.AG降低性高氯性酸中毒 92.应用人工呼吸机治疗呼吸衰竭和无自主呼吸的病人,若通气量过小,可导致: A.呼吸性酸中毒 B.呼吸性碱中毒 C.代谢性酸中毒 D.代谢性碱中毒 E.呼吸性碱中毒合并代谢性酸中毒 93.矿井塌陷引起通风不良可引起酸碱平衡紊乱的类型是: A.呼吸性碱中毒 B.呼吸性酸中毒 C.代谢性酸中毒 D.代谢性碱中毒 E.代谢性酸中毒合并呼吸性碱中毒 94.慢性呼吸性酸中毒时,机体代偿的主要方式是: A.细胞外液缓冲 B.呼吸代偿 C.细胞内缓冲 D.肾脏代偿 E.骨骼代偿 95.下列哪一项不是呼吸性酸中毒病因: A.呼吸中枢及呼吸肌麻痹 B.气道阻塞 C.肺部疾患通气障碍 D.肺泡弥散障碍 E.通风不良 96.慢性呼吸性酸中毒时,机体代偿的主要方式是: A.细胞外液缓冲 B.呼吸代偿 C.细胞内缓冲 D.肾脏代偿 E.骨骼代偿 97.酸中毒对心肌收缩性的影响是: A.先增强后减弱 B.先减弱后增强 C.减弱 D.增强 E.不变

[X型题] 98.阴离子间隙增大型正常血氯性酸中毒常见于: A.酮症酸中毒患者 B.晚期慢性肾功能衰竭患者 C.乳酸酸中毒患者 D.水杨酸中毒患者 E.呕吐患者 99.呼吸性碱中毒时机体的代谢调节包括: A.细胞内外离子交换代偿增强,细胞外液氢离子升高,钾离子下降 B.细胞内外离子交换代偿增强,细胞外液氢离子钾离子均升高 C.经肾脏代偿调节,肾小管上皮细胞排氢离子减少 D.呼吸运动加快,二氧化碳排出过多 E.呼吸运动减弱二氧化碳排出减少 100. 呼吸性酸中毒初期表现为:
A.血浆中H2CO3浓度原发性降低
B.血浆中H2CO3浓度原发性增高
C.PaCO2>6.25kPa,AB<SB
D.PaCO2>6.25kPa, AB>SB
E. PaCO2<6.25kPa, AB>SB 101. 代谢性酸中毒时,对中枢神经系统危害较大的因素是:
A.pH下降 B.高钾血症 C.CO2升高
D.r- 氨基丁酸增多 E. r- 氨基丁酸减少 102.低氯性碱中毒常见于: A.使用过多的速尿、利尿酸等利尿剂 B.原发性醛固酮增多症 C.Cushin氏综合症 D.碳酸氢盐摄入过多 E.纠正酸中毒时,乳酸钠溶液输注过量 103.对氯反应性碱中毒时,下列哪些叙述是正确的: A.补充生理盐水可纠正低氯性代谢性的碱中毒 B.补充生理盐水后不能纠正低氯性代谢性碱中毒 C.速尿利尿剂应用过多可引起低氯性代谢性碱中毒 D.严重呕吐可引起低氯性代谢性碱中毒 E.碱性液体输注过量 104.阴离子间隙(AG)正常型高氯性酸中毒见于: A.近端肾小管性酸中毒 B.急性重症性肾功能衰竭 C.慢性肾功能衰竭早期 D.严重腹泻 E.急性呼吸道阻塞 105.高热时可引起酸碱平衡紊乱的类型有: A.代谢性酸中毒合并呼吸性酸中毒 B.代谢性酸中毒合并呼吸性碱中毒 C.代谢性碱中毒合并呼吸性碱中毒 D.代谢性酸中毒 E.代谢性碱中毒

[B型题] A.血液中缓冲系统的作用 B.肺的调节作用 C.肾的调节作用 D.组织细胞的缓冲作用 E.中枢神经的调节作用 106.对排出挥发性酸性物质具有重要作用的是: A.缓冲能力最持久 B.缓冲能力强,但有一定限制 C.缓冲作用发生最快 D.调节能力最强 E.缓冲能力最小,调节能力也小 107.肺的调节作用: 108.细胞的缓冲作用: 109.肾的调节作用: 110.骨骼的缓冲: 111.血液的缓冲系统: A.代谢性酸中毒 B.代谢性碱中毒 C.呼吸性酸中毒 D.呼吸性碱中毒 E.酸碱平衡正常 112. HCO3-原发性减少见于: 113. HCO3-原发性增加见于: 114. HCO3-继发性增加见于: A.代谢性酸中毒 B.代谢性碱中毒 C.呼吸性酸中毒 D.呼吸性碱中毒 E.酸碱平衡正常 115.碳酸根离子原发性减少见于: 116.碳酸根离子原发性增加: 117.碳酸根离子继发性增加: A.呼吸系统代偿 B.细胞内、外液缓冲作用 C.肾脏代偿 D.骨骼缓冲作用 E.心血管代偿作用 118.急性呼吸性酸中毒时机体对酸碱平衡紊乱的主要代偿方式是: 119.慢性呼吸性酸中毒时机体对酸碱平衡紊乱的主要代偿方式是: 120.引起代谢性酸中毒合并代谢性碱中毒: A.心跳,呼吸骤停 B.慢性肺源性心脏病 C.急性胃肠炎剧烈加腹泻 D.发热呕吐 121.引起代谢性酸中毒合并呼吸性碱中毒:

[名词解释] 122.代谢性酸中毒 123.呼吸性碱中毒 124.二氧化碳结合力 125.标准碳酸氢盐(SB) 126.实际碳酸氢盐(AB) 127.缓冲碱(BB) 128.碱剩余(BE) 129.阴离子间隙(AG)

[问答题] 130.叙述代谢性酸中毒时,机体有哪几种代偿性调节?哪种代偿方式出现最早?哪种代偿方式作用最持久?详细叙述这两种代偿方式。 131.详细叙述颅脑损伤后易引起哪种酸碱平衡紊乱?其发生机制是什么? 132.叙述酸中毒时对机体危害最大的是哪两个方面。 133.何谓"脱水热",简述其发生机制? 134.为什么低渗性脱水病人容易休克? 135. 慢性阻塞性肺气肿病人,在合并中毒性休克四天后,突然出现呼吸心跳骤停。经及时抢救后病人呼吸心跳恢复,血生化检验提示:PH5.2。[HCO-3]=16mEq%/L,PaCO2>2kpa AG>mEq%/L 。请分析此时体内酸碱平衡所处的状况。 136.举例说明机体内存在着的酸碱共轭体系: NaHCO/HCO NaHPO/NaHPO 137. 慢性阻塞性肺气肿病人,在合并中毒性休克四天后,突然出现呼吸心跳骤停。经及时抢救后病人呼吸心跳恢复,血生化检验提示:PH5.2。[HCO-3]=16mEq%/L,PaCO2>2kpa AG>mEq%/L 。请分析此时体内酸碱平衡所处的状况。 138.酸碱紊乱时代偿出现较迟,维持时间较长的是:

[填空题] 139.乳酸性酸中毒时,反映酸碱平衡紊乱的生化指标变化特征是PH________[HCO3]_________,血氯__________,AG___________. 140.引起呼吸性酸中毒的原因包括________________或 ___________________. 141.碱中毒时,血红蛋白氧离曲线_____,血氧含量,血氧饱和度_____,而组织的供氧量是_______的,因为_____________________________. 142.在排除普通膳食条件下摄取酸物质的因素,人体内酸物质来源主要包括_______________和__________________。 143.血浆缓冲系统包括_________,________,__, 而细胞外液的PH主要取决于_______________________的比值 144.红细胞的缓冲系统包括有 _______,_________,________。_________其中以__________最为重要。 145. 已知氢离子在远、近曲小管内随尿排出的机制是有区别的,远曲小管在重吸收__________的同时,H+是随H2CO3而不是象在近曲小管那样随_________而排出体外的。 146.肺在酸碱平衡的调节作用是通过______________来调节血浆_________的变化。 147.标准碳酸氢盐是指全血标本在标准条件下,即在温度___________氧饱和度__________________和_________________平衡后,_________________. 148.在一个化学反应中,能释放_________的化学物质称为酸,例如______ 和________;能接受_______的化学物质称为碱,例如_____和_________。

参考答案

[A型题]

|1.A |2.C |3.D |
|109.A |110.E |111.C |
|11 |113.B |114.C |
|2.A | | |
|115.A |116.B |117.C |
|118.B |119.C |120.C |
|121.D | | | [名词解释] 122.因通气过度引起的血浆H2CO3浓度原发性减少,PaCO下降和AB<SB
123.指血浆HCO-中的CO2含量,其正常值为23~31mmol/L.

124. 是指全血在标准条件下(38摄氏温度,100%的血红蛋白饱和度,PCO为5.32kPa时测得的血浆中的HCO-浓度,正常范围是22-27mmol/L 125.指血标本与空气隔绝下,实际的PCO和血氧饱和度条件下,测得的血浆HCO-浓度,正常范围是22-27mmol/L 126.是血液中一切具有缓冲作用的负离子的总和,正常范围是45-55mmol/L 127.在温度为38摄氏温度,PCO 5.32kPa.Hb15Og/L和血氧饱和度为100%时,用酸或碱将1L全血或血浆的PH滴至到PH7.40时所用的酸或碱的量用mmol/L表示,正常范围为0±3mEq/L 128.指血清中未测定的阴离子量减去未测定的阳离子量的差值。即AG=UA-UC正常范围为mmol/L 129. 指血浆HCO-浓度原发性减少,血浆PH SB AB BB和CO C P均降低。 [问答题] 130. 代谢性酸中毒时有血液的缓冲,肺,肾,细胞内及骨骼肌等五种代偿方式,其中以肺代偿出现的最早,肾脏代偿方式作用最持久。 [H+] 刺激外周化学感受器→呼吸中枢 →呼吸运动加深加快→[H2CO3]↓ 使[H2CO3]/[NaHCO3]=1:20 刺激肾小管上皮细胞 中碳酸酐酶活性→ 肾排氢离子↑回收NaHCO3↑ →使[NaHCO3] ------- [H2CO3] 的比值维持在20:1
131. 颅脑损伤后极易引起呼吸性酸中毒 颅脑受损→易抑制呼吸中枢的兴奋性→呼吸运动↓通气不足→CO2排出↓→CO潴留CO体内↑ →[CO+H+→H2CO↑(原发性增高)AB>SB[PaCO>6.25Pa、CO C P↑ 再抑制呼吸中枢兴奋性,引起通气不足的恶性循环 132.高渗性脱水严重的病例,尤其体温调节功能发育尚未完全的婴幼儿,易出现体温升高。 发生机制:1.严重脱水引起循环血量减少,通过RAA系统和交感神经系统使皮肤血管收缩,不显性排汗减少,导致散热障碍,2.细胞外液渗透压显著升高,细胞内水分外移,细胞内脱水,体温调节中枢的热敏神经无功能障碍,而使体温调定点上移,结果导致体温升高. 133.①低渗性脱水病人血浆渗透压降低,无口渴感,饮水少 134.②血浆渗透压低,ADH分泌减少,尿量不减少 135.③细胞外液渗透压低于细胞内液,细胞外液向细胞内转移,使细胞外液进一步减少

[填空题] 139.降低;降低;正常 增大 140.①二氧化碳排出障碍;②二氧化碳吸入过多 141.①左移;②升高;③下降;④氧合血红蛋白不易释放氧气 142. ①机体新陈代谢时产生能量的同时释放出的氢离子 ②物质分解代谢过程中产生的有机酸
143. NaHCO3 NaHPO4 Na-Pr [NaHCO3] ----------- ----------- 和 ------- ------------- H2CO3 NaH2PO4 H-Pr [H2CO3]
144. KHCO3 K2HPO4 K-Hb K-HbO2 --------- ---------- ------- 和 ---------Hb与HbO2缓冲系统 H2CO3 KH2PO4 H-Hb H-HbO2
145. NaHCO3, H2O 146.频率和幅度; HCO浓度
147. ①温度为38摄氏温度; ②氧饱和度为100%; ③PCO2为5.32kPa ④血浆中的HCO3-浓度
148. H+;HCl ;H2SO4;H+ ;OH- ;SO42-

难题解析

试题 某肺心病患者,血气分析及电解质测定结果如下:PH 7.26,PaCO2 85.8mmHg, HCO3- 37.8mmol/人 CI- 90mmol/人 Na+ 140mmol/人 下列诊断中最有可能是哪一种: A.呼吸性酸中毒 B.代谢性酸中毒 C.呼吸性酸中毒合并代谢性酸中毒 D.呼吸性酸中毒合并代谢性碱中毒 E.呼吸性碱中毒 答案:C
解析:本病例PaCO2明显高于正常,结合患者有肺心病,表明存在呼吸性酸中毒。该病例AG值为140-(90+37.8)=12.2mmol/L,在正常范围内。预测HCO3-=0.4×(85.8-40)±3=18.3±mmol/L,HCO3-=24+HCO3=42.3±3=39.3~45.3mmol/L,而实测HCO3-为37.8mmol/L,低于预测值范围的最低值,表明还同时存在着可使HCO3-降低的代谢性酸中毒,故可诊断呼吸性酸中毒合并代谢性酸中毒,由于同时存在着两种酸中毒,所以pH明显降低。

试题 血气分析测定结果为PaCO2降低,同时伴有HCO3-升高,可诊断为: A.呼吸性酸中毒
B.代谢性酸中毒
C.呼吸性碱中毒
D.代谢性碱中毒
E.呼吸性碱中毒合并代谢性碱中毒
答案:E
解析:在单纯酸碱失衡中,PaCO2降低,HCO3也降低,而以上测定中,PaCO2降低而HCO3-反升高,表明决不可能是单纯性酸碱失衡。患者的PaCO2下降可判断存在呼吸性碱中毒,患者HCO3-升高,说明还合并代谢性碱中毒,即患有呼吸性碱中毒合并代谢性碱中毒,这种病人肯定为失代偿,pH将很高。

试题 碱中毒时出现神经肌肉应激性亢进,手足抽搐的主要原因是:
A.血清K+减少 B.血清CI- 减少 C.血清Ca2+减少
D.血清Na+减少 E.血清Mg2+减少
答案:C
解析:碱中毒时,血pH升高,血清钙中结合钙浓度升高,而游离钙浓度减少,出现神经肌肉应激性亢进,手足抽搐等症状。 试题 某慢性肾功能不全患者,因上腹部不适呕吐而急诊入院,血气分析结果:PH 7.39 PaCO2 43.8mmHg HCO3- 26.6mmol/人 Na+ 142mmol/人 Cl- 96.5mmol/人诊断属哪一种酸碱失衡:
A.AG增高性代谢性酸中毒
B.AG正常性代谢性酸中毒
C.AG增高性代谢性酸中毒合并代谢性碱中毒
D.AG正常性代谢性酸中毒合并代谢性碱中毒
E.AG增高性代谢性酸中毒合并呼吸性酸中毒
答案:C
解析:本病例pH 、HCO3-和PaCO2均在正常范围内,饭店无明显的酸碱失衡,但AG=Na+-(CL-+HCO3-)=142-(96.5+26.2)=18.3mmol/L,比正常12.0mmol/L高7.3mmol/L,提示有高AG代谢性酸中毒.如属单纯性高AG代谢性酸中毒,AG升高应有相等mmol/L的HCO3-下降.但实测HCO3-为26.2mmol/L,反高于均数24mmol/L,加上患者有呕吐,其HCO3-可原发性升高而血氯降低(96.5mmol/L),提示合并代谢性碱中毒,所以本病例应诊断为高AG性代谢性酸中毒合并代谢性碱中毒。如不计算AG,可误诊为血气指标正常。

试题 下列哪一项混合性酸碱失衡不可能出现: A.代谢性酸中毒合并代谢性碱中毒 B.呼吸性酸中毒合并呼吸性碱中毒 C.代谢性酸中毒合并呼吸性碱中毒 D.代谢性酸中毒合并呼吸性酸中毒 E.代谢性碱中毒合并呼吸性碱中毒
答案:B
解析:两种酸碱紊乱并存的情况主要有下列六种可能:(1)呼吸性酸中毒合并代谢性酸中毒;(2)呼吸性酸中毒合并代谢性碱中毒;(3)呼吸性碱中毒合并代谢性酸中毒;(4)呼吸性碱中毒合并代谢性碱中毒;(5)代谢性酸中毒合并代谢性碱中毒(主要指高AG代谢性酸中毒合并代谢性碱中毒);(6)高AG代谢性酸中毒合并正常AG代谢性酸中毒。但呼吸性酸中毒和呼吸性碱中毒,不可能同时存在,因为PaCO2不可能过高和过低同时存在,即肺通气不可能过度和不足同时并存。

试题 AG增高提示机体可发生: A.高氯血性代谢性酸中毒 B.正氯血性代谢性酸中毒 C.代谢性碱中毒 D.呼吸性酸中毒 E.呼吸性碱中毒
答案:B
解析:负离子间隙(AG)是指从血浆中未测得的负离子量,减去未测定的正离子量的差值。AG增高反映了高AG的代谢性酸中毒,即正常氯血性代谢性酸中毒。

试题 溃疡病并发幽门梗阻患者,因反复呕吐入院,血气分析结果如下:
PH>7.48,PaCO26.4kPa(48mmHg),HCO-336mmol/L该病人酸碱失衡的
类型是:
A.代谢性酸中毒
B.代谢性碱中毒
C.呼吸性酸中毒
D.呼吸性碱中毒
E.混合性酸碱中毒
答案:A
解析:根据病史及血气分析结果,病人原发酸碱失衡是HCO3-过多,而导致pH增高,似属代谢性碱中毒。代谢性碱中毒是否并发其他酸碱紊乱,可从预测代偿公式判断:

试题 阴离子间隙(AG)增高的代谢性酸中毒常见于: A.腹泻 B.使用乙酰唑胺利尿 C.糖尿病 D.肾小管性酸中毒 E.大量输入生理盐水
答案:C
解析:AG增高是指未测定的阴离子酸根在体内积蓄过多,主要见于乳酸性酸中毒,酮症性酸中毒及严重肾功能衰竭所致的酸中毒。糖尿病常可导致酮血症,是AG增高的代谢性酸中毒常见的病因,而上述其他原因,均不引起AG增高。

试题 慢性呼吸性酸中毒时,机体代偿的主要方式是: A.细胞外液缓冲 B.呼吸代偿 C.细胞内缓冲 D.肾脏代偿 E.骨骼代偿
答案:B
解析;由于呼吸性酸中毒的原因是呼吸障碍,所以呼吸系统往往不能发挥代偿作用。血浆的非碳酸氢盐缓冲系统对增高的碳酸有缓冲作用,并使HCO3-略有增加,但增加很有限,细胞内外离子交换及细胞内缓冲也很有限。主要的代偿措施为肾脏代偿,表现在肾产氨排H+和NaHCO3重吸收显著增多,从而使大量H+随尿排出,而血浆HCO3-有较多升高,使HCO3-/H2CO3比值接近正常,但肾脏代偿较慢,需要3~5天后才发挥最大代偿效应。所以在慢性呼吸性酸中毒时,肾脏代偿是主要的代偿方

试题 下列哪一项不是呼吸性酸中毒病因: A.呼吸中枢及呼吸肌麻痹 B.气道阻塞 C.肺部疾患通气障碍 D.肺泡弥散障碍 E.通风不良
答案;D
解析:因CO2弥散能力很强(比氧约大20倍),肺泡气体弥散障碍一般不会导致CO2蓄积产生,只有通气障碍及通风不良造成PaCO2>45mmHg(6.0kPa)时,才产生呼吸性酸中毒。
式。

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