— 生理適應 · EASY · MCQ —
護理師評估一位體液過多的病人，應預期出現何種臨床發現？
A nurse is assessing a client with fluid volume excess. Which clinical finding should the nurse expect?
- ADecreased blood pressure血壓下降
- BPoor skin turgor皮膚彈性差
- CBounding pulse✓ 正解脈搏強而有力
- DConcentrated urine尿液濃縮
— Explanation · 中文詳解 —
體液過多（Fluid Volume Overload）導致血管內壓力增加，常見臨床表現包括強而有力的搏動（Bounding pulse）、頸靜脈怒張、高血壓、肺部濕囉音及水腫。A選項低血壓見於體液不足；B選項皮膚彈性差是脫水表現；D選項濃縮尿液通常與脫水有關，而非體液過多。
Fluid volume overload increases intravascular pressure. Typical clinical findings include a strong, bounding pulse, jugular venous distention, hypertension, pulmonary crackles, and edema. Option A (low blood pressure) is seen in fluid volume deficit; Option B (poor skin turgor) reflects dehydration; and Option D (concentrated urine) is usually associated with dehydration rather than fluid volume excess.
✦ 台美臨床差異
台美兩地皆重視水腫與脈搏評估，但在電子病歷紀錄中，美國更強調體重波動（Daily weight）作為體液監測的黃金標準。