— 生理適應 · HARD · MCQ —
護理師照護一位有心衰竭病史的病人。哪項臨床指標是偵測液體滯留最敏感的早期指標？
A nurse is caring for a client with a history of heart failure. Which clinical indicator is most sensitive for early detection of fluid overload?
- ABlood pressure changes血壓變化
- BDaily weights✓ 正解每日體重
- CLung auscultation肺部聽診
- DPresence of peripheral edema周邊水腫的存在
— Explanation · 中文詳解 —
心衰竭病人的液體滯留評估中，每日固定時間、相同儀器、穿著輕便衣物測量的「每日體重」是最敏感的早期指標。液體滯留往往在臨床可見水腫（通常需要增加 4.5 公斤以上體重）或聽診出現肺部囉音前，就已透過體重增加反映出來。其他選項如水腫屬於後期徵象；肺部聽診雖重要，但屬身體評估，受限於護理師聽診技巧與病人肺部基底狀況；血壓變化則受血管彈性、藥物與交感神經影響，不具備偵測早期水腫的專一性。
Daily weights are the most sensitive and reliable indicator of fluid status changes, as even small amounts of retained fluid result in measurable weight gain. Clinical signs like lung crackles or peripheral edema typically appear only after significant fluid accumulation has occurred.