— 照護管理 · MEDIUM · SATA —
一位心衰竭病史病人，哪些表現需要立即評估？（選所有適合的）
A nurse is caring for a client with a history of heart failure. Which findings require prompt assessment? (Select all that apply.)
- AIncreased dyspnea at rest✓ 正解休息時呼吸困難加劇
- BWeight gain of 3 lbs in 24 hours✓ 正解24小時內體重增加3磅
- CIncreased pedal edema✓ 正解足部水腫增加
- DOccasional mild cough偶爾輕微咳嗽
- EClear lung sounds肺部聽診音清晰
— Explanation · 中文詳解 —
心衰竭（Heart Failure）病人出現失代償（Decompensation）的臨床徵象時，必須立即進行評估與處置。呼吸困難（Dyspnea）、體重短時間內的快速增加（Fluid retention）、以及周邊水腫增加，皆代表體液負荷超載（Fluid overload），可能引發急性肺水腫，屬高危險狀態。
Signs of decompensation in heart failure require immediate assessment. Increased dyspnea at rest, rapid weight gain (3 lbs in 24 hours suggests fluid retention), and increased pedal edema all indicate fluid overload, which can precipitate acute pulmonary edema. Occasional mild cough and clear lung sounds are not red flags requiring immediate evaluation.