— 生理適應 · EASY · MCQ —
一位病人呈現體液不足症狀，下列哪項評估發現是脫水最可靠的指標？
A client presents with signs of fluid volume deficit. Which assessment finding is the most reliable indicator of dehydration in this client?
- ADry mucous membranes乾燥的黏膜
- BSudden decrease in body weight✓ 正解體重突然減輕
- CPoor skin turgor皮膚彈性不佳
- DIncreased thirst口渴增加
— Explanation · 中文詳解 —
體液狀態最客觀且精確的指標是每日體重。體重在短時間內明顯減輕，通常直接反映體液流失量（1 公斤相當於 1 公升水）。其他選項如口乾、皮膚彈性、口渴均受年齡、環境濕度及個體感受等主觀或生理因素影響，精確度遠不及體重監測。
The most objective and accurate indicator of fluid status is daily body weight. A significant short-term decrease in body weight directly reflects fluid loss (1 kg is equivalent to 1 L of water). Other findings such as dry mouth, skin turgor, and thirst are influenced by age, environmental humidity, and subjective or physiologic factors of the individual, and are far less precise than weight monitoring.
✦ 台美臨床差異
美台護理臨床皆強調「每日量體重」作為 fluid balance 的金標準，但執行落實度皆有待加強。