— 生理適應 · EASY · SATA —
護理師評估一位疑似體液過載的病人，應觀察到哪些表現？（選所有適合的）
A nurse is assessing a client with signs of fluid volume overload. Which findings should the nurse expect? (Select all that apply.)
- ABounding pulse✓ 正解脈搏強勁
- BDistended neck veins✓ 正解頸靜脈怒張
- CCrackles upon lung auscultation✓ 正解聽診肺部時出現濕囉音
- DElevated hematocrit血球容積比升高
- EPeripheral edema✓ 正解周邊水腫
— Explanation · 中文詳解 —
體液過載會導致血管內壓力升高，出現強勁脈搏（bounding pulse）、頸靜脈怒張（JVD）及週邊水腫。水分滲出至肺泡造成肺部濕囉音（crackles）。至於血球容積比（hematocrit）在體液過載時通常會因稀釋效應而下降，而非上升，故 D 選項錯誤。
Involving staff in the planning and decision-making process fosters ownership and reduces anxiety associated with change. Participative management addresses resistance by giving employees a voice, which builds trust and cooperation. Ignoring feedback, keeping plans secret, or mandating compliance without input often leads to increased resistance and lower morale.
✦ 台美臨床差異
兩地臨床皆以這些臨床徵象為液體過載的標準評估指標。