一位有心臟衰竭病史的病人因呼吸短促與端坐呼吸入院。護理師觀察到肺底有濕囉音，且兩天內體重增加了 3 公斤。病人最可能正在經歷哪種生理適應變化？
A client with a history of heart failure is admitted with shortness of breath and orthopnea. The nurse notes crackles in the lung bases and a 3 kg weight gain over two days. Which physiological adaptation is the client most likely experiencing?
- AHypovolemic shock低血容量性休克
- BRespiratory alkalosis呼吸性鹼中毒
- CFluid volume excess✓ 正解體液容積過量
- DDiabetes insipidus尿崩症
心臟衰竭病人的核心問題是心輸出量不足，導致腎臟血流減少並啟動 RAAS 系統，進而造成水鈉滯留。當液體過度堆積時，會導致靜水壓升高，液體滲入肺泡形成肺水腫（表現為濕囉音與端坐呼吸）。體重增加是液體滯留最精確的指標，1 公斤體重約等於 1 公升液體。此題考查護理師對容量負荷過重症狀的辨識能力，這是心衰竭照護中最基礎的病理生理概念，優先處置通常包括給予利尿劑與限制水分攝取。
The core problem in heart failure is inadequate cardiac output, which reduces renal perfusion and activates the renin-angiotensin-aldosterone system (RAAS), leading to sodium and water retention. As fluid accumulates, hydrostatic pressure rises and fluid leaks into the alveoli, producing pulmonary edema (manifested as crackles and orthopnea). Weight gain is the most precise indicator of fluid retention—approximately 1 kg corresponds to 1 L of fluid. This question tests the nurse's ability to recognize the signs of fluid overload, which is the most fundamental pathophysiologic concept in heart-failure care. Priority management typically includes administering a diuretic and restricting fluid intake.
美國護理教育強調每日量體重（Daily Weight）作為心衰竭管理的核心指標，且 LPN 常被授權執行測量，但由 RN 進行肺部聽診與整體評估；台灣臨床則多將體重測量視為例行公事，較強調由醫師聽診後確認水腫程度。