— 降低風險 · EASY · SATA —
護理師評估病人是否有低血容性休克徵象。預期會出現哪些發現？（選所有適合的）
A nurse is assessing a client for signs of hypovolemic shock. Which findings should the nurse expect? (Select all that apply.)
- ATachycardia✓ 正解心跳過速
- BHypotension✓ 正解低血壓
- CIncreased urine output尿量增加
- DCool, clammy skin✓ 正解皮膚濕冷
- EConfusion or lethargy✓ 正解意識混亂或嗜睡
— Explanation · 中文詳解 —
低血容性休克是因體液流失導致灌流不足。身體代償機制會導致心跳加速（Tachycardia）以維持心輸出量。隨失血加劇，血壓下降（Hypotension）、皮膚因周邊血管收縮呈現濕冷（Cool, clammy skin）、大腦灌流不足導致意識混亂（Confusion），且因腎臟灌流減少導致尿量下降（Oliguria）。
Hypovolemic shock results from inadequate perfusion due to fluid loss. The body's compensatory mechanisms produce tachycardia to maintain cardiac output. As blood loss progresses, blood pressure drops (hypotension), the skin becomes cool and clammy due to peripheral vasoconstriction, cerebral hypoperfusion causes confusion, and renal hypoperfusion leads to decreased urine output (oliguria).
✦ 台美臨床差異
無顯著差異，此為全球統一的臨床生理病理原則。