— 生理適應 · EASY · MCQ —
護理師評估一位液體容積過多的病人，應預期出現何種徵象？
A nurse is assessing a client with fluid volume excess. Which finding should the nurse expect?
- ADistended neck veins✓ 正解頸靜脈怒張
- BIncreased urine specific gravity尿液比重大幅增加
- CDry mucous membranes黏膜乾燥
- DDecreased blood pressure血壓下降
— Explanation · 中文詳解 —
液體容積過多（Fluid Volume Excess）導致血管內壓力升高。頸靜脈怒張（JVD）是反映右心房壓升高與全身性液體超負荷的特徵性徵象。其他選項皆為液體容積不足（脱水）的表現，如尿比重上升、血壓下降及黏膜乾燥。
Fluid volume excess raises intravascular pressure. Jugular venous distention (JVD) is a hallmark sign reflecting elevated right atrial pressure and systemic fluid overload. The other options reflect fluid volume deficit (dehydration), such as elevated urine specific gravity, decreased blood pressure, and dry mucous membranes.
✦ 台美臨床差異
台美臨床對於評估 JVD 的技巧一致，皆需將病患頭部抬高 30-45 度進行觀察。