— 生理適應 · MEDIUM · MCQ —
心衰竭病人若出現下列何項發現，應立即回報醫師？
A nurse is caring for a client with a history of heart failure. Which clinical finding should be reported to the physician immediately?
- AMild dyspnea after walking步行後出現輕微呼吸困難
- BWeight gain of 3 lbs in 2 days✓ 正解2 天內體重增加 3 磅
- CHeart rate of 80 bpm心率 80 bpm
- DBlood pressure of 120/80 mmHg血壓 120/80 mmHg
— Explanation · 中文詳解 —
心衰竭（Heart Failure）病人因心臟泵血功能不足，容易導致體液滯留。體重變化是評估液體滯留最敏感且可靠的指標。短期內體重增加（如 2 天內增加 3 磅）通常意味著體內積聚了水分，預示著心衰竭可能出現急性代償失調（Acute Decompensation），若不及時處理，極易發展為肺水腫或嚴重的循環系統負荷過重，因此必須立即回報醫師進行藥物調整。
In heart failure, rapid weight gain is the most sensitive indicator of fluid retention and potential acute decompensation. A gain of 3 lbs in 2 days suggests significant fluid accumulation that could lead to pulmonary edema or increased cardiac workload. Therefore, this finding requires immediate reporting to the physician for prompt medication adjustment.