— 生理適應 · EASY · MCQ —
護理師照護一位疑似低血容積性休克的病人，應預期出現何種臨床表現？
A nurse is caring for a client with a suspected diagnosis of hypovolemic shock. Which clinical manifestation should the nurse anticipate?
- AHypotension✓ 正解低血壓
- BBradycardia心搏過緩
- CWarm, flushed skin溫暖、潮紅的皮膚
- DIncreased urine output尿量增加
— Explanation · 中文詳解 —
低血容積性休克因體液大量流失，導致有效循環血量減少，壓力感受器會代償性引起心跳過速。當代償機制失敗時，病人會出現低血壓。C 選項熱紅皮膚常見於敗血性休克，D 選項尿量會因腎灌流不足而減少，B 選項則是休克時的代償反應。
In hypovolemic shock, large fluid losses lead to decreased effective circulating volume, and baroreceptors compensate by inducing tachycardia. When compensatory mechanisms fail, the client develops hypotension. Option C, warm and flushed skin, is more commonly seen in septic shock; Option D, urine output decreases because of reduced renal perfusion; and Option B, bradycardia, is not the compensatory response in shock (tachycardia is).
✦ 台美臨床差異
美台兩地對於休克病人的監測標準一致，主要差別在於美國護理師在給予預防性輸液時的自主權較高。