— 生理適應 · EASY · SATA —
下列哪些評估結果顯示個案正處於體液容積過多？（選所有適合的）
Which assessment findings indicate that a client is experiencing fluid volume excess? (Select all that apply.)
- ABounding peripheral pulses✓ 正解周邊脈搏強而有力
- BPresence of S3 heart sound✓ 正解出現第三心音 (S3)
- CDecreased urine specific gravity尿液比重的降低
- DDistended neck veins✓ 正解頸靜脈怒張
- ECrackles upon lung auscultation✓ 正解聽診肺部時出現囉音
— Explanation · 中文詳解 —
體液容積過多會導致循環負荷增加。臨床表現包括頸靜脈怒張、心臟出現第三心音（S3）、肺部聽診出現囉音（肺水腫前兆）、動脈搏動強大。尿比重通常會增加（脫水時），若體液過多時尿比重通常會降低（稀釋），但在心衰竭時因腎灌流不足可能出現濃縮尿。故選 A, B, D, E。
Fluid volume excess increases circulatory load. Clinical findings include distended neck veins, an S3 heart sound, crackles on lung auscultation (a precursor to pulmonary edema), and bounding arterial pulses. Urine specific gravity is generally elevated in dehydration; with fluid volume excess it is typically decreased (dilution), although in heart failure it may appear concentrated due to reduced renal perfusion. Therefore, the correct answers are A, B, D, and E.
✦ 台美臨床差異
美國護理師常使用集中監測儀表板；台灣護理師多依靠定時人工記錄與交班報告。