— 生理適應 · MEDIUM · SATA —
哪些評估結果顯示病人正處於液體容積不足的狀態？（選所有適合的）
Which assessment findings indicate that a client is experiencing fluid volume deficit? (Select all that apply.)
- AIncreased urine specific gravity✓ 正解尿液比重的增加
- BTachycardia✓ 正解心搏過速
- CDistended neck veins頸靜脈怒張
- DDry mucous membranes✓ 正解黏膜乾燥
- EHypotension✓ 正解低血壓
— Explanation · 中文詳解 —
脫水時，腎臟會濃縮尿液導致比重升高，心跳加速（代償性心搏過速），口腔黏膜乾燥，且因循環血量減少導致低血壓。頸靜脈怒張（Distended neck veins）通常與液體容積過多（Fluid Volume Overload）有關，故為錯誤選項。
In dehydration, the kidneys concentrate the urine and the specific gravity rises; heart rate increases (compensatory tachycardia); mucous membranes become dry; and decreased circulating volume causes hypotension. Distended neck veins are typically associated with fluid volume overload, so this option is incorrect.
✦ 台美臨床差異
美國護理師常執行床邊身體評估以判斷水分狀態；台灣護理師則高度仰賴 I/O 紀錄與醫囑點滴速率。