— 基本照護與舒適 · MEDIUM · MCQ —
病人的護理診斷為「體液容積不足」。哪項評估結果支持此診斷？
A client has a nursing diagnosis of 'Deficient Fluid Volume'. Which assessment finding supports this?
- ADistended neck veins頸靜脈怒張
- BBilateral pitting edema雙側凹陷性水腫
- CIncreased urine output尿液排出量增加
- DTachycardia and hypotension✓ 正解心搏過速與低血壓
— Explanation · 中文詳解 —
體液不足時，身體透過代償機制增加心跳（Tachycardia）以維持心輸出量，而低血壓（Hypotension）則是血管內容積下降的直接表現。水腫（B）與頸靜脈怒張（A）均為體液過載的指標；尿量增加（C）通常見於利尿劑作用或體液過多時。
When fluid volume is deficient, the body activates compensatory mechanisms — increased heart rate (tachycardia) — to maintain cardiac output, while hypotension is a direct manifestation of decreased intravascular volume. Edema (B) and distended neck veins (A) are both indicators of fluid overload; increased urine output (C) is commonly seen with diuretic effect or fluid excess.
✦ 台美臨床差異
兩地對體液監測的臨床指標解讀完全一致。