— 生理適應 · EASY · SATA —
一位體液容積過多的病人，護理師預期會觀察到哪些臨床表現？（選所有適合的）
A nurse is caring for a client with fluid volume excess. Which clinical manifestations should the nurse expect to find? (Select all that apply.)
- ABounding pulse✓ 正解脈搏強而有力
- BDistended neck veins✓ 正解頸靜脈怒張
- CCrackles upon lung auscultation✓ 正解聽診肺部有囉音
- 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 —
體液容積過多（Fluid Volume Excess）會導致血管內壓力上升。體現為頸靜脈怒張、周邊水腫、聽診肺部濕囉音（水分滲入肺泡），脈搏強而有力（Bounding pulse）。尿比重會下降（尿液稀釋），而非增加。
Fluid volume excess raises intravascular pressure. It manifests as jugular venous distention, peripheral edema, moist crackles on lung auscultation (fluid leaking into the alveoli), and a strong, bounding pulse. Urine specific gravity is decreased (urine is dilute) rather than increased.
✦ 台美臨床差異
兩地對體液超載的評估原則一致。台灣臨床常使用中心靜脈壓(CVP)監測，而美國更強調病人的日常體重監測作為關鍵指標。