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生理適應 · EASY · SATA

下列哪些評估發現表示病人有體液容積過多現象?(選所有適合的)

Which assessment findings indicate that a client is experiencing fluid volume overload? (Select all that apply.)

  • ABounding peripheral pulses✓ 正解
    周邊脈搏強勁
  • BDistended neck veins✓ 正解
    頸靜脈怒張
  • CPresence of moist crackles in the lung bases✓ 正解
    肺底部出現濕性囉音
  • DDecreased blood pressure
    血壓降低
  • EWeight gain of 3 lbs in 24 hours✓ 正解
    24 小時內體重增加 3 磅
Explanation · 中文詳解

體液容積過多(Fluid volume overload)又稱為高血容積(Hypervolemia),是由於體內水分與鈉滯留導致血管內壓力升高。臨床表現主要集中在心血管負荷過重與肺部淤血。護理師在評估時,應運用液體動力學概念,觀察靜脈回流、心輸出量及組織間隙水腫。此題的核心在於識別循環系統超載的典型徵象,以及區分其與脫水(低容積)的生理差異。

Fluid volume overload, also known as hypervolemia, results from retention of water and sodium leading to increased intravascular pressure. Clinical manifestations primarily involve cardiovascular overload and pulmonary congestion. When assessing, the nurse should apply principles of fluid dynamics to observe venous return, cardiac output, and interstitial edema. The key to this question is recognizing the typical signs of circulatory overload and distinguishing them from the physiological features of dehydration (hypovolemia).

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