— 生理適應 · EASY · SATA —
護理師評估一位體液過多的病人，預期會出現哪些症狀？（選所有適合的）
A nurse is assessing a client with fluid volume overload. Which findings should the nurse anticipate? (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✓ 正解肺部濕囉音
- DDecreased blood pressure血壓下降
- EPolyuria多尿
— Explanation · 中文詳解 —
體液過多時，循環血量增加，導致脈搏強而有力（Bounding）、頸靜脈因靜脈淤積而怒張、肺部因水分滲入肺泡導致囉音（Crackles）。血壓通常會升高而非降低，尿量可能因腎臟代償而變多，但不是直接的體液過多指標。
In fluid volume overload, circulating volume increases, leading to a bounding pulse, distended neck veins due to venous congestion, and crackles in the lungs as fluid moves into the alveoli. Blood pressure usually rises rather than falls, and urine output may increase as a compensatory renal response, but it is not a direct indicator of fluid overload.
✦ 台美臨床差異
臨床實務中，台美對於體液過多的理學評估重點並無顯著差異，護理重點均在於水分監測。