— 降低風險 · MEDIUM · MCQ —
評估一位病人是否有低血容（hypovolemia）。下列何者支持此診斷？
A nurse is assessing a client for signs of hypovolemia. Which finding supports this diagnosis?
- AIncreased urine output尿量增加
- BMoist mucous membranes黏膜濕潤
- CFlattened neck veins✓ 正解頸靜脈塌陷
- DBounding peripheral pulses周邊脈搏強勁
— Explanation · 中文詳解 —
低血容（Hypovolemia）是指體內循環血量不足，導致組織灌流下降。頸靜脈壓力（Jugular Venous Pressure, JVP）是評估循環容積的關鍵指標。當血容不足時，靜脈系統內壓力降低，頸靜脈會呈現塌陷（Flattened）狀態。其他選項如尿量減少（而非增加）、脈搏微弱（而非強勁）、黏膜乾燥（而非濕潤）才是低血容的典型臨床表現。
Hypovolemia refers to inadequate circulating blood volume, leading to decreased tissue perfusion. Jugular venous pressure (JVP) is a key indicator of circulating volume. When intravascular volume is decreased, venous pressure falls and the neck veins appear flat. Other findings such as decreased (not increased) urine output, weak (not bounding) pulses, and dry (not moist) mucous membranes are the typical clinical manifestations of hypovolemia.