— 生理適應 · MEDIUM · SATA —
下列哪些發現顯示病人出現體液過多？（選所有適合的）
Which assessment findings indicate a client is experiencing fluid volume excess? (Select all that apply.)
- ABounding peripheral pulses✓ 正解周邊脈搏強而有力
- BCrackles upon lung auscultation✓ 正解肺部聽診出現捻发音（crackles）
- CElevated blood pressure✓ 正解血壓升高
- DDecreased urine output尿液排出量減少
- EJugular vein distension✓ 正解頸靜脈怒張
— Explanation · 中文詳解 —
體液過多（Hypervolemia）導致血管內壓力增加。臨床表現為頸靜脈怒張、血壓升高、因血管容積增加導致脈搏跳動強勁，肺部聽診可聞及濕囉音（水分滲入肺泡）。減少尿量並非體液過多的直接指標，相反地，有時因心臟輸出增加，初期可能有排尿增加，或由腎功能衰竭導致的尿量減少。D 項非體液過多的必然依據。
Fluid volume excess increases intravascular pressure, leading to clinical signs such as jugular vein distension, elevated blood pressure, bounding peripheral pulses, and crackles upon lung auscultation due to fluid backing up into the lungs. Decreased urine output is not a direct indicator of fluid overload, as output may initially increase due to higher cardiac output or decrease due to renal failure.
✦ 台美臨床差異
台美對體液過多的評估一致，但美國護理師常配合超音波或中央靜脈壓數據綜合判斷。