— 生理適應 · EASY · MCQ —
病人診斷為液體容積不足。護理師預期會看到何種發現？
A client is diagnosed with fluid volume deficit. Which assessment finding is expected?
- ATachycardia✓ 正解心搏過速
- BBounding pulse脈搏強而有力
- CPeripheral edema周邊水腫
- DDistended neck veins頸靜脈怒張
— Explanation · 中文詳解 —
液體容積不足（脫水）導致血容量下降，身體會透過增加心跳次數（Tachycardia）來維持心輸出量。Bounding pulse（脈搏強而有力）、頸靜脈怒張與周邊水腫則為液體過多（Volume overload）的特徵。
Fluid volume deficit (dehydration) leads to decreased blood volume, and the body compensates by increasing heart rate (tachycardia) to maintain cardiac output. A bounding pulse, distended neck veins, and peripheral edema are characteristic of fluid volume overload.
✦ 台美臨床差異
兩地護理師對體液平衡的評估皆重視生命徵象，美國護理師常結合皮膚彈性（Skin turgor）評估。