— 生理適應 · EASY · SATA —
下列哪些評估發現代表體液容積不足？（選所有適合的）
Which assessment findings are indicative of fluid volume deficit? (Select all that apply.)
- ATachycardia✓ 正解心跳過速
- BDecreased skin turgor✓ 正解皮膚彈性減退
- CBounding peripheral pulses周邊脈搏強而有力
- DConcentrated urine✓ 正解尿液濃縮
- EDry mucous membranes✓ 正解黏膜乾燥
— Explanation · 中文詳解 —
體液不足導致代償機制啟動，心搏過速（Tachycardia）以維持心輸出量。細胞間液減少使皮膚彈性變差。ADH 分泌增加導致尿液濃縮，黏膜乾燥也是典型徵兆。Bounding pulses（強而有力的脈搏）通常見於液體超載或周邊血管擴張，不符。
Fluid volume deficit is indicated by tachycardia as a compensatory mechanism, decreased skin turgor, concentrated urine due to ADH release, and dry mucous membranes. Bounding peripheral pulses are typically associated with fluid volume excess rather than deficit.
✦ 台美臨床差異
台美護理師評估重點一致，但美國護理師常利用 POCUS (Point-of-Care Ultrasound) 評估頸靜脈深度來輔助診斷；台灣此技術多用於醫師或專科護理師。