— 生理適應 · EASY · SATA —
護理師評估一位體液容積過多的病患，預期會觀察到哪些臨床表現？（選所有適合的）
A nurse is assessing a client with fluid volume excess. Which clinical findings should the nurse expect to observe? (Select all that apply.)
- ABounding pulse✓ 正解強而有力的脈搏
- BDistended neck veins✓ 正解頸靜脈擴張
- CMoist crackles upon lung auscultation✓ 正解聽診肺部時出現濕性囉音
- DIncreased urine specific gravity尿液比重大幅增加
- EPeripheral edema✓ 正解周邊水腫
— Explanation · 中文詳解 —
體液過多會導致血管內容積增加，出現脈搏強而有力（Bounding pulse）、頸靜脈怒張。肺部會因液體滲出出現濕性囉音（Crackles），周邊組織會出現凹陷性水腫。尿比重（Urine specific gravity）在體液過多時通常會降低，因水分過多導致尿液稀釋。
Fluid volume excess increases intravascular volume and produces a strong, bounding pulse and distended neck veins. Fluid leaks into the alveoli, causing audible moist crackles on auscultation, and into peripheral tissues, producing dependent edema. Urine specific gravity is usually decreased in fluid overload because of hemodilution, not increased.
✦ 台美臨床差異
美國護理師常使用中心靜脈壓（CVP）監測；台灣臨床多依賴身體評估（理學檢查）與攝入排出量（I/O）。