— 照護管理 · MEDIUM · SATA —
護理師評估一位有心衰竭病史的病人。下列哪些發現暗示體液容積過載（Fluid volume overload）？（選所有適合的）
A nurse is assessing a client with a history of heart failure. Which findings indicate fluid volume overload? (Select all that apply.)
- ABounding peripheral pulses✓ 正解周邊脈搏強勁
- BCrackles upon lung auscultation✓ 正解聽診肺部時出現囉音
- CWeight loss of 2 lbs in 24 hours24小時內體重減輕2磅
- DJugular vein distension✓ 正解頸靜脈怒張
- EDependent edema✓ 正解下垂部位水腫
— Explanation · 中文詳解 —
體液容積過載（Fluid volume overload）常見於心衰竭病人。臨床表徵包括血管內壓升高，導致頸靜脈怒張（JVD）、周邊脈搏強而有力（Bounding pulses），以及因肺水腫導致的肺部囉音（Crackles）。肢體水腫（Dependent edema）也是常見表現。體重減輕則是脫水的徵象，與此題相反。
Fluid volume overload is commonly seen in clients with heart failure. Clinical manifestations include elevated intravascular pressure leading to jugular vein distension (JVD), bounding peripheral pulses, and pulmonary crackles due to pulmonary edema. Dependent edema is also a common finding. Weight loss, in contrast, is a sign of dehydration and is opposite to what would be expected here.