— 基本照護與舒適 · MEDIUM · MCQ —
哪項評估發現顯示病人出現體液容積不足？
Which assessment finding indicates that a client is experiencing fluid volume deficit?
- ADistended neck veins頸靜脈怒張
- BDecreased serum osmolarity血清滲透壓降低
- CBounding pulses脈搏強而有力
- DIncreased hematocrit✓ 正解血球容積比增加
— Explanation · 中文詳解 —
體液容積不足（脫水）會導致血液濃縮，使紅血球容積比（Hematocrit）上升。靜脈怒張、跳動強且強力的脈搏與血清滲透壓下降，均為體液容積過多（Fluid volume overload）的跡象。脫水時應呈現脈搏微弱、血壓下降與尿量減少。
Fluid volume deficit, or dehydration, leads to hemoconcentration, which results in an increased hematocrit level as plasma volume decreases. In contrast, signs such as distended neck veins, bounding pulses, and decreased serum osmolarity are indicative of fluid volume excess rather than deficit.
✦ 台美臨床差異
美方護理師常依據實驗數據進行獨立判斷；台灣護理師則多依賴實驗室報告與醫師的診斷評估。