— 生理適應 · MEDIUM · SATA —
一位病人出現體液缺失症狀，護理師預期會發現什麼？（選所有適合的）
A client presents with signs of fluid volume deficit. Which assessment findings should the nurse expect? (Select all that apply.)
- ATachycardia✓ 正解心跳過速
- BIncreased skin turgor皮膚彈性增加
- COrthostatic hypotension✓ 正解姿勢性低血壓
- DDark, concentrated urine✓ 正解深色且濃縮的尿液
- EElevated hematocrit✓ 正解血球容積比升高
— Explanation · 中文詳解 —
體液缺失時，身體為了維持灌流會產生代償反應。心跳加快（心搏過速）補償心輸出量下降；姿位性低血壓反映血量不足；尿液濃縮是因為腎臟保留水分；血比容（Hematocrit）則因血液濃縮而升高。皮膚彈性差（Turgor poor）才是正確的體徵，增加則反之。
Fluid volume deficit triggers compensatory mechanisms such as tachycardia to maintain cardiac output and orthostatic hypotension due to reduced circulating volume. The kidneys conserve water, leading to dark, concentrated urine, while hemoconcentration results in an elevated hematocrit level.
✦ 台美臨床差異
兩地均強調測量姿勢性血壓作為診斷標準，台灣臨床對於老人脫水的護理評估亦採取相似指標。