— 生理適應 · EASY · SATA —
下列哪些臨床發現顯示病患出現液體容積過多？（選所有適合的）
Which of the following clinical findings indicate that a client is experiencing fluid volume excess? (Select all that apply.)
- ABounding pulse✓ 正解脈搏強而有力
- BDistended neck veins✓ 正解頸靜脈擴張
- CDecreased blood pressure血壓下降
- DPresence of moist crackles in lungs✓ 正解肺部出現濕性囉音
- EWeight loss體重減輕
— Explanation · 中文詳解 —
液體容積過多（Fluid Volume Excess）會增加血管內壓力，導致脈搏強而有力（Bounding pulse）、頸靜脈怒張（JVD）及肺部積水產生濕囉音（Crackles）。體重會增加而非減少，且血壓通常會升高而非降低。這些症狀反映了循環負荷過重。
Fluid volume excess increases intravascular pressure, leading to clinical signs such as a bounding pulse, distended neck veins, and moist crackles due to pulmonary congestion. These findings reflect circulatory overload, whereas weight loss and decreased blood pressure are associated with fluid volume deficit.
✦ 台美臨床差異
台美護理教學中對 fluid overload 的評估指標非常一致，均將水腫與肺部囉音視為關鍵指標。