— 生理適應 · EASY · MCQ —
護理師評估一位體液過多的患者，應預期出現何種發現？
A nurse is assessing a client with fluid volume excess. Which finding should the nurse anticipate?
- ADry mucous membranes黏膜乾燥
- BBounding pulse✓ 正解脈搏強而有力
- CConcentrated urine尿液濃縮
- DDecreased blood pressure血壓下降
— Explanation · 中文詳解 —
體液過多（Fluid volume excess / Hypervolemia）會導致全身血流量增加，心臟必須更用力泵血。臨床表現包括頸靜脈怒張、濕性囉音（Crackles）、水腫以及脈搏強而有力（Bounding pulse）。這些症狀反映了循環負荷過重，護理師在評估時應特別注意這些生命徵象與身體徵象。
Fluid volume excess (hypervolemia) increases circulating blood volume, forcing the heart to pump more forcefully. Clinical findings include jugular venous distention, crackles, edema, and a bounding pulse, reflecting circulatory overload. Nurses should pay particular attention to these vital and physical signs during assessment.