— 降低風險 · EASY · SATA —
護理師評估一位病人是否有體液容積過負荷徵兆，應包含哪些發現？（選所有適合的）
A nurse is assessing a client for signs of fluid volume overload. Which findings are expected? (Select all that apply.)
- ABounding pulse✓ 正解強而有力的脈搏
- BDistended neck veins✓ 正解頸靜脈怒張
- CCrackles in the lungs✓ 正解肺部囉音
- DIncreased blood pressure✓ 正解血壓升高
- ESunken eyes眼窩凹陷
— Explanation · 中文詳解 —
體液容積過負荷（Fluid Overload）臨床表現包括：脈搏強大（Bounding）、頸靜脈怒張（JVD）、肺部囉音（Crackles）與血壓升高。眼窩凹陷（Sunken eyes）為脫水的特徵，與過負荷臨床表現完全相反。
Fluid volume overload manifests as bounding pulse (increased vascular volume), distended neck veins (right-sided cardiac strain), lung crackles (pulmonary congestion), and elevated blood pressure (increased hydrostatic pressure). Sunken eyes are a hallmark of dehydration, the opposite condition.
✦ 台美臨床差異
美台對 Fluid Overload 的臨床判斷準則高度一致，皆包含 JVD 與肺音評估。