— 生理適應 · HARD · SATA —
護理師照護一位肝硬化合併腹水的病人。下列哪些評估發現需要立即就醫？（選所有適合的）
A nurse is caring for a client with liver cirrhosis and ascites. Which assessment findings require immediate medical attention? (Select all that apply.)
- AAbdominal distention腹部膨脹
- BFever and chills✓ 正解發燒和畏寒
- CDecreased urine output✓ 正解尿量減少
- DNew onset of confusion✓ 正解新發的意識混亂
- EWeight gain of 1 lb in 24 hours24 小時內體重增加 1 磅
— Explanation · 中文詳解 —
肝硬化病人常伴隨腹水，若出現發燒、意識改變或尿量減少，往往暗示嚴重的併發症。自發性細菌性腹膜炎（SBP）是肝硬化腹水病人的致死主因之一，發燒與畏寒是常見表現。肝性腦病變（Hepatic Encephalopathy）則常因毒素累積出現意識混亂。尿量減少則需警惕肝腎症候群（Hepatorenal Syndrome）。
Fever and chills suggest spontaneous bacterial peritonitis, decreased urine output may indicate hepatorenal syndrome, and new-onset confusion points to hepatic encephalopathy; all are serious complications requiring immediate medical intervention. Abdominal distention and minor weight gains are expected findings in ascites and do not typically warrant urgent action.