— 生理適應 · MEDIUM · SATA —
一位病人呈現低血容性休克徵象，護理師預期會發現哪些評估結果？（選所有適合的）
A client presents with signs of hypovolemic shock. Which assessment findings should the nurse expect? (Select all that apply.)
- ATachycardia✓ 正解心跳過速
- BIncreased urine output尿量增加
- CHypotension✓ 正解低血壓
- DCool and clammy skin✓ 正解皮膚冰冷且濕冷
- EBradycardia心跳過緩
— Explanation · 中文詳解 —
低血容性休克導致組織灌流不足。身體透過交感神經代償引發心跳過速（Tachycardia）以維持心輸出量，但長期失血導致血壓下降（Hypotension）。周邊血管收縮造成皮膚冷濕（Cool and clammy），腎臟灌流不足則使尿量減少（Oliguria）。
Hypovolemic shock produces inadequate tissue perfusion. The body compensates through sympathetic activation, causing tachycardia in an attempt to maintain cardiac output, but sustained blood loss eventually leads to hypotension. Peripheral vasoconstriction makes the skin cool and clammy, and decreased renal perfusion produces oliguria.
✦ 台美臨床差異
美國護理師在休克管理中常被授權執行更積極的液體復甦；台灣醫療模式中醫師主導輸液處方更為明顯。