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基本照護與舒適 · MEDIUM · SATA

護理師評估一位病人的脫水狀態。下列哪些徵象應納入觀察?(選所有適合的)

A nurse is assessing a client for dehydration. Which signs should the nurse look for? (Select all that apply.)

  • APoor skin turgor✓ 正解
    皮膚彈性差
  • BDry mucous membranes✓ 正解
    黏膜乾燥
  • CIncreased urine output
    尿量增加
  • DTachycardia✓ 正解
    心搏過速
  • EWeight gain
    體重增加
Explanation · 中文詳解

脫水(Dehydration)是臨床常見的體液失衡問題。護理評估應關注「體液流失」的徵象:皮膚彈性(Skin Turgor)變差是因為真皮層水分減少;黏膜乾燥反映全身性水分不足;心跳加快(Tachycardia)則是身體為了維持心輸出量(Cardiac Output)而對低血容量做出的代償性反應。尿量減少(而非增加)亦是腎臟為了保留水分的表現。體重減輕(Weight loss)而非增加,是評估脫水程度最敏感的指標之一。

Dehydration is a common fluid imbalance encountered clinically. Nursing assessment should focus on signs of "fluid loss": poor skin turgor results from reduced dermal water content; dry mucous membranes reflect systemic dehydration; and tachycardia is the body's compensatory response to maintain cardiac output in the setting of low blood volume. Urine output decreases (rather than increases) as the kidneys retain water. Weight loss (not gain) is one of the most sensitive indicators of dehydration severity.

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