— 生理適應 · MEDIUM · MCQ —
護理師正在照顧一位嚴重脫水的病人。何項評估發現最令人擔憂？
A nurse is caring for a client with severe dehydration. Which assessment finding is most concerning?
- ADry mucous membranes黏膜乾燥
- BLethargy and confusion✓ 正解嗜睡與意識混亂
- CUrine output of 15 mL/hr尿量為 15 mL/hr
- DWeak, thready pulse脈搏微弱且細速
— Explanation · 中文詳解 —
嚴重脫水（Severe dehydration）會導致全身有效循環血量不足，進而引發器官灌流不良。在所有評估指標中，中樞神經系統的狀態最為敏感且危急。意識改變（如嗜睡、混亂）表示腦部灌流不足，可能已發展至脫水性休克或嚴重的電解質失衡，這比黏膜乾燥、尿量減少或脈搏微弱更具急迫性與危險性，必須優先處理。
Lethargy and confusion are the most concerning findings because they indicate compromised cerebral perfusion and potential central nervous system dysfunction due to severe dehydration. While dry mucous membranes, low urine output, and weak pulses are signs of hypovolemia, altered mental status signals a more critical and immediate threat to life. This symptom suggests the client may be approaching or experiencing hypovolemic shock.