— 生理適應 · MEDIUM · SATA —
對於腎衰竭病人，下列哪些徵象顯示早期液體過多？（選所有適合的）
Which of the following signs are indicative of early fluid volume excess in a client with renal failure? (Select all that apply.)
- ABounding peripheral pulses✓ 正解周邊脈搏強而有力
- BDistended neck veins✓ 正解頸靜脈怒張
- CPresence of moist crackles in lung bases✓ 正解肺底部出現濕囉音
- DDecrease in blood pressure血壓下降
- EPresence of peripheral edema✓ 正解出現周邊水腫
— Explanation · 中文詳解 —
腎衰竭病人因排尿功能受損，液體滯留會導致循環血容量增加（Fluid volume excess）。早期徵象包括血管系統與肺部壓力變化。護理師評估時需運用「生理適應」核心概念，識別液體過多導致的循環負荷過重與水腫表現。當身體液體過多，血管內壓力升高會表現為強而有力的脈搏、靜脈怒張，且液體滲出至組織間隙造成周邊水腫，滲出至肺泡則產生濕囉音。
Fluid volume excess in renal failure leads to increased circulatory volume and hydrostatic pressure, manifesting as bounding pulses, distended neck veins, and peripheral edema. As fluid accumulates in the alveoli, moist crackles are heard in the lung bases, indicating pulmonary congestion rather than the hypotension associated with dehydration.