護理師評估高齡病人時，哪些發現顯示可能存在體液容積不足？（選所有適合的）
A nurse identifies which findings as indications of fluid volume deficit in an elderly client? (Select all that apply.)
- APoor skin turgor✓ 正解皮膚彈性差
- BOrthostatic hypotension✓ 正解姿勢性低血壓
- CDistended neck veins頸靜脈怒張
- DConcentrated urine✓ 正解尿液濃縮
- EElevated BUN levels✓ 正解BUN 數值升高
高齡病人因體液貯存量減少及口渴機制退化，極易發生體液容積不足（Fluid Volume Deficit）。臨床評估指標包括皮膚彈性變差（注意：高齡者皮膚彈性本就較差，需評估胸骨處）、姿勢性低血壓（代表循環血量不足）、尿液濃縮（尿比重上升）以及實驗室數值如 BUN 上升（濃縮現象）。頸靜脈怒張則反映體液容積過多（Fluid Volume Excess），是體液過負荷的指標，與題幹敘述矛盾。
Elderly clients are highly susceptible to fluid volume deficit because of decreased total body water reserves and a blunted thirst mechanism. Clinical indicators include diminished skin turgor (note: baseline skin elasticity is already reduced in older adults, so assessment should be performed over the sternum), orthostatic hypotension (reflecting reduced circulating volume), concentrated urine (elevated specific gravity), and laboratory values such as elevated BUN (from hemoconcentration). Distended neck veins, in contrast, reflect fluid volume excess and indicate fluid overload, which is inconsistent with the stem.