— 生理適應 · MEDIUM · MCQ —
護理師正在照護一位嚴重脫水的病人。哪項評估發現需要立即介入？
A nurse is caring for a client with severe dehydration. Which assessment finding requires immediate intervention?
- ADecreased skin turgor皮膚彈性減退
- BHypotension and weak, rapid pulse✓ 正解低血壓及微弱快速脈搏
- CDry mucous membranes黏膜乾燥
- DUrine specific gravity of 1.035尿液比重大 1.035
— Explanation · 中文詳解 —
嚴重脫水可能導致循環衰竭，表現為低血壓（hypotension）和脈搏微弱、快速（weak, rapid pulse）。這是生命危險的狀況，需要立即進行靜脈輸液補充體液和電解質，並監測生命徵象。其他選項均為脫水症狀，但相對不緊急。
Hypotension and a weak, rapid pulse are critical signs of hypovolemic shock, indicating severe circulatory compromise that requires immediate resuscitation. While decreased skin turgor, dry mucous membranes, and high urine specific gravity confirm dehydration, they do not pose the same immediate life-threatening risk as hemodynamic instability.
✦ 台美臨床差異
美國對於嚴重脫水或休克病人的復甦流程有明確的指引（如 Surviving Sepsis Campaign），強調早期診斷與介入；台灣的急重症照護也有類似標準，但資源整合與團隊協作的效率可能因地點而異。