— 生理適應 · MEDIUM · SATA —
病人疑似低血容積休克，護理師預期會出現哪些評估結果？（選所有適合的）
A client is admitted with suspected hypovolemic shock. Which assessment findings should the nurse expect? (Select all that apply.)
- ATachycardia✓ 正解心搏過速
- BIncreased urine output尿量增加
- CHypotension✓ 正解低血壓
- DCool, clammy skin✓ 正解皮膚濕冷
- EWeak, thready pulses✓ 正解脈搏微弱且細速
— Explanation · 中文詳解 —
低血容積休克是身體為了代償低循環血量所產生的生理反應。心跳加快（代償）、血壓下降（失代償）、皮膚濕冷（血液重分配至核心器官）、脈搏細弱（每搏輸出量減少）。尿量減少（少尿）才是正確現象，因為腎臟灌流不足會啟動 RAAS 系統來保留水分。
Hypovolemic shock is a physiological response in which the body compensates for decreased circulating blood volume. Tachycardia (compensatory), hypotension (decompensation), cool and clammy skin (blood redistributed to core organs), and weak, thready pulses (decreased stroke volume) are characteristic findings. Urine output decreases (oliguria) rather than increases, because renal hypoperfusion activates the RAAS system to retain fluid.
✦ 台美臨床差異
美國教學強調早期識別代償現象；台灣臨床則習慣對休克病人使用升壓劑的介入較為迅速。