— 降低風險 · HARD · MCQ —
護理師對術後病人進行評估，哪項發現暗示病人正經歷內出血？
A nurse is performing a postoperative assessment on a client. Which finding suggests the client is experiencing internal hemorrhage?
- ABlood pressure 130/85 mmHg, heart rate 85 bpm血壓 130/85 mmHg，心率 85 次/分
- BBlood pressure 120/80 mmHg, heart rate 60 bpm血壓 120/80 mmHg，心率 60 次/分
- CBlood pressure 140/90 mmHg, heart rate 72 bpm血壓 140/90 mmHg，心率 72 次/分
- DBlood pressure 100/60 mmHg, heart rate 110 bpm✓ 正解血壓 100/60 mmHg，心率 110 次/分
— Explanation · 中文詳解 —
內出血早期症狀常表現為代償性心搏過速（Tachycardia）以維持心輸出量，隨後出現低血壓。選項 D 顯示心跳明顯加快且血壓偏低，是低血容量休克的典型徵象。其他選項血壓心跳相對穩定，未見急性休克前兆。
The early manifestations of internal hemorrhage typically present as compensatory tachycardia to maintain cardiac output, followed by hypotension. Option D demonstrates a markedly elevated heart rate together with low-trending blood pressure, which is the classic presentation of hypovolemic shock. The other options show relatively stable blood pressure and heart rate without precursors of acute shock.
✦ 台美臨床差異
美國護理師常利用 NEWS 評分系統迅速辨識惡化；台灣臨床多依賴資深護理師的臨床直覺與常規生命徵象記錄。