— 生理適應 · HARD · SATA —
護理師評估一位低血容性休克的病人，應預期觀察到哪些臨床表現？（選所有適合的）
A nurse is assessing a client with hypovolemic shock. Which clinical manifestations should the nurse expect to find? (Select all that apply.)
- ATachycardia✓ 正解心搏過速
- BHypotension✓ 正解低血壓
- COliguria✓ 正解少尿
- DFlushed, warm skin皮膚潮紅、溫暖
- EWeak peripheral pulses✓ 正解周邊脈搏微弱
— Explanation · 中文詳解 —
低血容性休克（Hypovolemic Shock）是因為循環血量減少，導致組織灌流不足。身體會啟動代償機制：交感神經興奮引發心搏過速（Tachycardia）以維持心輸出量；周邊血管收縮導致脈搏減弱及皮膚冷濕（非溫熱）；腎臟灌流減少導致尿量下降（Oliguria）。血壓降低（Hypotension）則是代償失效後的表現。
Hypovolemic shock is caused by reduced circulating blood volume, resulting in tissue hypoperfusion. The body activates compensatory mechanisms: sympathetic stimulation produces tachycardia to maintain cardiac output; peripheral vasoconstriction leads to a weak pulse and cool, clammy skin (not warm); and reduced renal perfusion leads to decreased urine output (oliguria). Hypotension is a manifestation of failed compensation.