— 降低風險 · MEDIUM · MCQ —
護理師評估一位病人是否有低血容性休克的跡象。下列哪項發現是最可靠的早期指標？
A nurse is assessing a client for signs of hypovolemic shock. Which finding is the most reliable early indicator?
- ADecreased urine output尿液排出量減少
- BCool, clammy skin皮膚冰冷潮濕
- CIncreased heart rate✓ 正解心跳速率增加
- DDecreased blood pressure血壓下降
— Explanation · 中文詳解 —
低血容性休克發生時，交感神經會代償性興奮，心跳加速（Tachycardia）是為了維持心輸出量，這是最先出現的生理代償機制。血壓下降通常是晚期表現，代表代償機制已衰竭。尿量減少也是重要指標，但心跳變化速度通常快於尿量變化。
Tachycardia is the most reliable early indicator of hypovolemic shock because it is a compensatory mechanism to maintain cardiac output when blood volume decreases. While decreased urine output and cool, clammy skin are also signs of shock, heart rate changes typically occur before blood pressure drops, which is considered a late sign of decompensation.
✦ 台美臨床差異
無顯著執業差異，兩地皆強調早期辨識心跳變化以預防休克惡化。