— 降低風險 · HARD · SATA —
護理師評估病人是否有潛在低血容積休克的跡象。下列哪些發現支持此診斷？（選所有適合的）
A nurse is assessing a client for signs of potential hypovolemic shock. Which findings would support this diagnosis? (Select all that apply.)
- ATachycardia✓ 正解心动过速
- BTachypnea✓ 正解呼吸过速
- CIncreased urine output尿量增加
- DCool, clammy skin✓ 正解皮肤冰冷潮湿
- EHypertension高血压
— Explanation · 中文詳解 —
低血容積休克是身體為了代償組織灌流不足而啟動的反應。心跳加速（Tachycardia）與呼吸過速（Tachypnea）是交感神經啟動的早期指標。末梢血管收縮導致皮膚冰冷潮濕。尿量反而會減少（少尿），血壓會下降而非上升。
Hypovolemic shock triggers compensatory responses to maintain tissue perfusion. Tachycardia and tachypnea are early signs of sympathetic activation. Peripheral vasoconstriction makes the skin cool and clammy. Urine output decreases (oliguria), and blood pressure drops rather than rises.
✦ 台美臨床差異
美國護理師常使用早期警示評分（MEWS）來偵測休克前兆；台灣臨床亦逐漸導入類似系統，但強調醫師即時評估。