護理師監測有心衰竭病史病人的體液過負荷徵兆。哪些發現顯示此狀況？（選所有適合的）
A nurse is monitoring a client with a history of heart failure for signs of fluid volume overload. Which findings are indicative of this condition? (Select all that apply.)
- AJugular venous distension✓ 正解頸靜脈怒張
- BCrackles upon auscultation of the lungs✓ 正解聽診肺部時出現爆裂音
- CFlattened neck veins when supine仰臥時頸靜脈扁平
- DPitting edema in the lower extremities✓ 正解下肢凹陷性水腫
- ERapid weight gain✓ 正解體重快速增加
心衰竭（heart failure）病人由於心臟泵血功能受損，無法有效將血液泵送到全身，導致體液在體內積聚，進而引發體液過負荷（fluid volume overload）。體液過負荷是心衰竭病人常見且可能危及生命的狀況，會加重心臟負擔，並導致肺水腫、周邊水腫等症狀。護理師必須能夠識別這些徵兆，以便及早介入。 本題的正確選項 A、B、D、E 都是體液過負荷的典型臨床表現。頸靜脈怒張（Jugular venous distension）反映右心房壓升高；肺部囉音（crackles）是肺水腫的表現；下肢凹陷性水腫（pitting edema）是體液在組織間隙積聚的結果；快速體重增加則直接反映了體內液體的過度積聚。這些徵兆共同提示病人處於體液過負荷狀態，需要立即處理，如限制液體攝取、給予利尿劑等。
Fluid volume overload in heart failure manifests as jugular venous distension due to increased right atrial pressure, pulmonary crackles from fluid accumulation in the alveoli, and pitting edema in the lower extremities. Rapid weight gain is also a key indicator of acute fluid retention, necessitating immediate interventions such as fluid restriction and diuretic administration.
美國門診照護強調 24 小時增重 2-3 磅需回報；台灣臨床亦以此為重要的出院衛教基準。