— 降低風險 · MEDIUM · SATA —
護理師照護一位有心衰竭病史的病人，哪些臨床徵象暗示液體過多？（選所有適合的）
A nurse is caring for a client with a history of heart failure. Which clinical signs suggest fluid overload? (Select all that apply.)
- ABounding pulse✓ 正解強而有力的脈搏
- BDistended jugular veins✓ 正解頸靜脈怒張
- CCrackles on lung auscultation✓ 正解聽診肺部出現囉音
- DPoor skin turgor皮膚彈性差
- EWeight loss體重減輕
— Explanation · 中文詳解 —
心衰竭病人因心臟泵血功能受損，導致液體滯留與血容積過多（Fluid volume excess）。臨床評估重點在於血管壓力與肺部積水跡象。液體過多會導致靜脈回流壓力升高，出現頸靜脈怒張；血容積增加導致心輸出量負荷加重，出現心跳強勁（洪脈）；肺部微血管壓力上升則會導致肺水腫，出現囉音。護理師需透過監測體重、攝入與排出量（I&O）及肺音來評估治療成效。
Signs of fluid overload in heart failure include a bounding pulse due to increased blood volume, distended jugular veins from elevated central venous pressure, and crackles indicating pulmonary edema. These findings reflect the heart's inability to pump effectively, leading to systemic and pulmonary congestion.