— 生理適應 · EASY · SATA —
護理師評估液體容積過負荷的病患，預期會出現哪些臨床表現？（選所有適合的）
A nurse is assessing a client with fluid volume overload. Which clinical manifestations should the nurse expect? (Select all that apply.)
- ADistended neck veins✓ 正解頸靜脈怒張
- BBounding peripheral pulses✓ 正解周圍脈搏強而有力
- CCrackles on auscultation of the lungs✓ 正解肺部聽診有囉音
- DIncreased urine output尿量增加
- EWeight gain✓ 正解體重增加
— Explanation · 中文詳解 —
液體過負荷（高血容積）會導致循環壓力增加。頸靜脈怒張、心跳脈搏充實（Bounding）、肺部囉音（肺水腫早期）及體重增加是典型表徵。D 選項是錯誤的，通常過負荷時身體會嘗試代償，但若腎功能受損或心衰竭，尿量反而常減少或無顯著增加。
Fluid volume overload raises circulatory pressure. Typical findings include distended neck veins, bounding pulses, lung crackles (early pulmonary edema), and weight gain. Option D is incorrect — urine output often decreases in renal- or cardiac-driven overload rather than increasing.
✦ 台美臨床差異
台美兩地在評估液體平衡時皆強調 Daily Weight，但美國護理師常需更頻繁參與利尿劑滴定與血中電解質監測的決策。