— 生理適應 · HARD · SATA —
病患因創傷懷疑低血容性休克，護理師預期會發現哪些徵象？（選所有適合的）
A client is admitted with suspected hypovolemic shock following trauma. Which assessment findings should the nurse expect? (Select all that apply.)
- ATachycardia✓ 正解心跳過速
- BHypertension高血壓
- COliguria✓ 正解少尿
- DCool, clammy skin✓ 正解冰冷潮濕的皮膚
- EMental confusion✓ 正解意識混亂
— Explanation · 中文詳解 —
低血容性休克是因血液流失導致細胞灌流不足。交感神經代償會引起心跳過速（Tachycardia）以維持心輸出量；尿量減少（Oliguria）是腎臟灌流不足的結果；周邊血管收縮導致皮膚濕冷（Cool, clammy skin）；腦部缺氧則表現為意識混亂（Mental confusion）。血壓應是下降（Hypotension）而非上升。
In hypovolemic shock, sympathetic compensation triggers tachycardia to maintain cardiac output, while vasoconstriction causes cool, clammy skin. Decreased renal perfusion leads to oliguria, and reduced cerebral perfusion results in mental confusion. Blood pressure typically decreases rather than increases as shock progresses.
✦ 台美臨床差異
美台對於休克監測標準一致，但美國醫院常配置 Shock Index 監測，台灣臨床多側重於監測 BP 與心跳變化。