— 生理適應 · EASY · SATA —
護理師為液體滯留過多的病患進行評估，應預期出現哪些臨床徵象？（選所有適合的）
A nurse is performing a physical assessment on a client with fluid volume overload. Which findings should the nurse expect? (Select all that apply.)
- ABounding pulse✓ 正解脈搏強而有力
- BDistended neck veins✓ 正解頸靜脈怒張
- CCrackle sounds in lung fields✓ 正解肺部聽診有爆裂音
- DWeight loss體重減輕
- EPeripheral pitting edema✓ 正解周邊壓陷性水腫
— Explanation · 中文詳解 —
液體滯留過多（Fluid volume overload）會導致循環血量增加，造成周邊血管壓力上升，臨床表現包括強而有力的脈搏（Bounding pulse）與頸靜脈怒張（Distended neck veins）。此外，血管內壓力升高會導致液體滲出至組織間隙，形成周邊水腫（Pitting edema），並進入肺部微血管，出現肺部濕囉音（Crackles）。
Fluid volume overload increases circulating blood volume and peripheral vascular pressure, producing a bounding pulse and distended neck veins. Increased hydrostatic pressure forces fluid into the interstitium causing peripheral pitting edema and into the pulmonary capillaries, producing crackles on auscultation.