— 降低風險 · MEDIUM · SATA —
護理師照護一位診斷為液體容積過載的病人。下列哪些臨床表現是預期會發現的？（選所有適合的）
A nurse is caring for a client who is diagnosed with fluid volume overload. Which clinical manifestations should the nurse expect to find? (Select all that apply.)
- ABounding, rapid pulse✓ 正解強而有力且快速的脈搏
- BCrackles upon lung auscultation✓ 正解聽診肺部時出現捻发音
- CIncreased blood pressure✓ 正解血壓升高
- DWeight loss體重減輕
- EDistended neck veins (JVD)✓ 正解頸靜脈擴張（頸靜脈怒張）
— Explanation · 中文詳解 —
液體過載（Hypervolemia）會導致血管內容積增加，出現脈搏強而快、血壓上升、頸靜脈怒張。水分溢出至間質與肺泡會導致肺部囉音（Crackles）。D 選項錯誤，體重應該是增加而非減輕，這是評估水分滯留最敏感的指標。
Fluid volume overload (hypervolemia) increases intravascular volume, producing a strong, rapid (bounding) pulse, elevated blood pressure, and distended neck veins. Fluid leaks into the interstitial space and alveoli, leading to pulmonary crackles. Option D is incorrect: weight should increase rather than decrease, and weight is the most sensitive indicator of fluid retention.
✦ 台美臨床差異
兩國對於液體過載的體徵評估規範一致，均強調每日量體重的重要性。