— 降低風險 · EASY · SATA —
護理師照護一位心衰竭病人。下列哪些徵象顯示有液體過度負荷（fluid overload）？（選所有適合的）
A nurse is caring for a client with a history of heart failure. Which findings indicate fluid overload? (Select all that apply.)
- APresence of S3 heart sound✓ 正解出現第三心音
- BCrackles in the lungs✓ 正解肺部囉音
- CDistended neck veins✓ 正解頸靜脈怒張
- DDecreased blood pressure血壓下降
- EPeripheral edema✓ 正解周邊水腫
— Explanation · 中文詳解 —
液體過度負荷會導致靜脈系統淤積與心臟擴張。常見徵象包括：S3 心音（心室舒張受限）、肺部囉音（肺水腫）、頸靜脈怒張（體循環壓力高）、周邊水腫。血壓在初期通常會升高，若血壓下降通常代表心輸出量嚴重受損，雖也是嚴重徵兆，但非負荷本身的直接徵象。
Fluid volume overload leads to venous congestion and cardiac dilation. Common signs include an S3 heart sound (limited ventricular relaxation), pulmonary crackles (pulmonary edema), jugular venous distension (elevated systemic pressure), and peripheral edema. Blood pressure is generally elevated initially; a fall in blood pressure usually indicates severely compromised cardiac output, which while also serious is not a direct sign of overload itself.
✦ 台美臨床差異
美台對心衰竭的身體評估標準一致，美國護理師在社區照顧中更常運用遠端監測系統追蹤這些徵象。