— 生理適應 · EASY · SATA —
下列哪些臨床徵象會讓護理師懷疑病人有液體過多（體液容積過負荷）？（選所有適合的）
Which of the following clinical signs would lead a nurse to suspect a client has fluid volume overload? (Select all that apply.)
- ABounding pulse✓ 正解脈搏強而有力
- BDistended neck veins✓ 正解頸靜脈擴張
- CDecreased blood pressure血壓下降
- DCrackles upon lung auscultation✓ 正解肺部聽診出現囉音
- EWeight loss體重減輕
— Explanation · 中文詳解 —
體液過多會導致循環血量增加，造成周邊血管搏動強勁（Bounding pulse）及頸靜脈怒張（JVD）。肺部聽診可聞及濕囉音（Crackles），代表肺水腫。血壓通常會升高而非降低，且體重應呈現增加趨勢。
Fluid volume overload increases circulating blood volume, producing a strong, bounding peripheral pulse and jugular venous distension (JVD). Auscultation of the lungs may reveal crackles, reflecting pulmonary edema. Blood pressure typically rises rather than falls, and the client's weight tends to increase.
✦ 台美臨床差異
無明顯差異，皆以理學檢查與監測體重做為診斷依據。