護理師評估一位主訴兩腳踝腫脹加劇的心臟衰竭病人。護理師聽到兩側肺底有囉音。哪項護理診斷最適合？
A nurse is assessing a client with heart failure who reports increased swelling in both ankles. The nurse notes bibasilar crackles. Which nursing diagnosis is most appropriate?
- ARisk for impaired skin integrity皮膚完整性受損風險
- BActivity intolerance活動不耐受
- CIneffective peripheral tissue perfusion周邊組織灌流無效
- DExcess fluid volume✓ 正解體液過多
心臟衰竭（Heart Failure）病人出現雙下肢水腫（Peripheral Edema）及肺底囉音（Bibasilar Crackles），明確指出體液滯留（Fluid Overload）的問題。這些徵象反映了心臟幫浦功能不足，導致體循環與肺循環壓力升高。護理診斷「過多體液（Excess Fluid Volume）」能精確涵蓋這些臨床表現，並引導後續護理重點，如監測每日體重、限制液體攝入及給予利尿劑。
In a client with heart failure, bilateral lower extremity edema (peripheral edema) and bibasilar crackles clearly indicate fluid overload. These findings reflect inadequate cardiac pump function leading to elevated systemic and pulmonary circulatory pressures. The nursing diagnosis 'Excess fluid volume' accurately captures these clinical manifestations and guides subsequent nursing priorities, such as monitoring daily weight, restricting fluid intake, and administering diuretics.