— 降低風險 · HARD · SATA —
護理師正在評估一位手術後病人，檢查是否有潛在出血跡象。下列哪些發現是低血容性休克的早期指標？（選所有適合的）
A nurse is assessing a client for signs of potential postoperative hemorrhage. Which findings are early indicators of hypovolemic shock? (Select all that apply.)
- ATachycardia✓ 正解心跳過速
- BRestlessness and anxiety✓ 正解煩躁與焦慮
- CIncreased urine output尿量增加
- DCool, clammy skin✓ 正解皮膚冰冷、濕黏
- EHypotension低血壓
— Explanation · 中文詳解 —
低血容性休克的早期徵兆為代償機制啟動，包括心跳加速以維持心輸出量，以及因組織缺氧導致的焦慮不安與皮膚濕冷。低血壓（Hypotension）通常屬於較後期的徵兆，此時體內儲備已耗盡，病情較為危急；尿量增加則與休克表現相反。
Early indicators of hypovolemic shock include tachycardia, restlessness, and cool, clammy skin as the body attempts to compensate for decreased circulating volume. Tachycardia maintains cardiac output, while peripheral vasoconstriction causes skin changes. Hypotension is a late sign indicating decompensation, and oliguria, not increased urine output, is expected.
✦ 台美臨床差異
美護理強調早期識別（Early Recognition）與 Rapid Response Team（RRT）機制；台灣臨床多倚賴護理師觀察後通知醫師處理。