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降低風險 · HARD · SATA

護理師評估一位疑似低血容休克的病人。哪些發現屬於早期警訊?(選所有適合的)

A nurse is assessing a client for signs of hypovolemic shock. Which findings would the nurse identify as early signs? (Select all that apply.)

  • ATachycardia✓ 正解
    心跳過速
  • BTachypnea✓ 正解
    呼吸過速
  • CRestlessness✓ 正解
    煩躁不安
  • DHypotension
    低血壓
  • ECold, clammy skin
    冰冷潮濕的皮膚
Explanation · 中文詳解

低血容休克(Hypovolemic shock)早期,身體透過交感神經代償來維持重要器官的灌流。此時會出現心跳加速(代償心輸出量下降)、呼吸加速(代償代謝性酸中毒)、以及焦慮不安(腦部缺氧初期反應)。低血壓通常是晚期徵兆,代表代償機制已崩潰,此時病情往往已不可逆。因此,識別早期徵兆對於搶救生命至關重要。

In the early phase of hypovolemic shock, the body compensates through sympathetic nervous system activity to maintain perfusion to vital organs. At this stage, tachycardia (compensating for decreased cardiac output), tachypnea (compensating for metabolic acidosis), and restlessness (the early cerebral response to hypoxia) appear. Hypotension is usually a late sign and indicates that compensatory mechanisms have failed, often at a point when the condition has become irreversible. Recognizing early signs is therefore critical to saving the patient's life.

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