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照護管理 · MEDIUM · MCQ

護理師評估一位脫水病人,哪項結果為預期表現?

A nurse is assessing a client for dehydration. Which finding is expected?

  • ADistended neck veins
    頸靜脈怒張
  • BDependent edema
    依賴性水腫
  • CBradycardia
    心動過緩
  • DTachycardia✓ 正解
    心動過速
Explanation · 中文詳解

脫水(Dehydration)導致血管內體液容積減少,造成靜脈回流下降與每搏輸出量(Stroke Volume)降低。為了維持足夠的心輸出量(Cardiac Output),身體會啟動交感神經系統,透過增加心跳速率(Heart Rate)來代償,因此心跳過速是脫水時常見的代償性臨床表現。護理師應評估此生理反應,並結合皮膚張力(Skin Turgor)、黏膜濕潤度及尿量等指標進行判斷。

Dehydration leads to decreased intravascular volume, reducing venous return and stroke volume. To maintain adequate cardiac output, the body activates the sympathetic nervous system, which compensates by increasing the heart rate; tachycardia is therefore a common compensatory clinical finding in dehydration. The nurse should evaluate this physiologic response in conjunction with skin turgor, mucous membrane moisture, and urine output.

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