護理師在評估早期低血容積休克的病人時，應預期出現哪些臨床表徵？（選所有適合的）
Which assessment findings should a nurse expect in a client diagnosed with early-stage hypovolemic shock? (Select all that apply.)
- ATachycardia✓ 正解心跳過速
- BDecreased urinary output✓ 正解尿量減少
- CCool, clammy skin✓ 正解皮膚冰冷潮濕
- DBounding peripheral pulses周邊脈搏強而有力
- EMental confusion精神混亂
低血容積休克早期階段，身體為了維持重要器官的灌流，會啟動交感神經系統（SNS）進行代償。心跳加快（心搏過速）是為了維持心輸出量（CO = HR x SV，SV 減少時 HR 必須代償）；腎臟偵測到灌流壓下降，會啟動 RAS 系統減少尿量，導致少尿。皮膚冷且濕冷是因為血液被分流到核心器官，周邊血管收縮所致。選項 D 的跳躍脈搏是心輸出量過高或血管阻力下降的特徵，與休克不符；選項 E 的意識混亂通常出現在休克晚期，因腦部灌流嚴重不足所致，而非早期代償期的表現。識別這些早期生理代償訊號是護理介入的黃金時間。
In the early stage of hypovolemic shock, the body activates the sympathetic nervous system (SNS) to maintain perfusion of vital organs. Tachycardia is a compensatory response to preserve cardiac output (CO = HR x SV; when SV falls, HR must rise to compensate). When the kidneys sense reduced perfusion pressure, the renin-angiotensin system is activated, reducing urine output and producing oliguria. The skin becomes cool and clammy because blood is shunted to core organs and peripheral vessels constrict. Option D, bounding pulses, reflects high cardiac output or decreased vascular resistance and is inconsistent with shock; option E, mental confusion, typically appears in late shock due to severely impaired cerebral perfusion and is not a feature of the early compensatory phase. Recognizing these early physiological compensatory signs marks the golden window for nursing intervention.
美國護理教育強調『Shock Index』(HR/SBP) 的計算來預判休克，台灣臨床實務上多依賴護理師的經驗判斷（如膚色、溫濕度）以及醫師開立的生理監測數據，較少由護理師主動進行數值比對預警。