— 生理適應 · MEDIUM · SATA —
護理師評估一位體液容積過負荷的病人。應預期出現哪些臨床表徵？（選所有適合的）
A nurse is assessing a client with signs of fluid volume overload. Which clinical findings should the nurse expect? (Select all that apply.)
- ABounding pulse✓ 正解強而有力的脈搏
- BDistended neck veins✓ 正解頸靜脈怒張
- CDecreased blood pressure血壓下降
- DCrackles upon lung auscultation✓ 正解聽診肺部時出現囉音
- EWeight loss體重減輕
— Explanation · 中文詳解 —
體液容積過負荷（Fluid volume overload/Hypervolemia）會導致血管內液體量過多，增加心臟負荷與靜脈壓力。臨床表現包括奔跳脈（Bounding pulse）、頸靜脈怒張（Distended neck veins）以及因肺部微血管壓力升高導致的肺部囉音（Crackles）。體重會因水分滯留而增加，血壓通常會升高。
Fluid volume overload increases circulating volume, leading to a bounding pulse, distended neck veins, and crackles due to pulmonary congestion. Blood pressure typically rises rather than decreases, and weight gain occurs from fluid retention rather than loss.