NurslixJournal
降低風險 · EASY · MCQ

一位液體負荷過多的病人,哪項評估結果是預期內的?

A nurse is assessing a client with fluid volume excess. Which finding is expected?

  • AConcentrated urine
    濃縮尿液
  • BHypotension
    低血壓
  • CPoor skin turgor
    皮膚彈性差
  • DBounding pulse✓ 正解
    搏動強勁的脈搏
Explanation · 中文詳解

核心概念:體液負荷過多(Fluid Volume Excess)的臨床表現。 為何正確答案對: A. 搏動性脈搏(Bounding pulse)是體液負荷過多的典型徵象。由於血管內循環血量增加,心臟搏出量(Cardiac Output)增加,導致脈搏跳動強而有力,感覺脈搏跳動明顯。 為何其他選項錯: B. 皮膚緊繃感(Poor skin turgor)是體液不足(Dehydration)的表現,表示皮膚彈性下降。 C. 低血壓(Hypotension)是體液不足或休克的表現,與體液過多相反。 D. 濃縮尿液(Concentrated urine)是身體試圖保留水分的表現,通常發生在體液不足或脫水時。體液過多的病人尿液通常是稀釋的。

Core concept: clinical manifestations of fluid volume excess. Why the correct answer is right: A. A bounding pulse is a classic sign of fluid volume excess. Because intravascular circulating volume is increased, cardiac output rises, producing a strong, forceful pulse that is easily palpable. Why the other options are wrong: B. Poor skin turgor is a sign of dehydration, reflecting decreased skin elasticity. C. Hypotension reflects fluid volume deficit or shock, the opposite of fluid overload. D. Concentrated urine reflects the body's attempt to conserve water and typically occurs with volume deficit or dehydration. Clients with fluid overload generally produce dilute urine.

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