— 生理適應 · EASY · MCQ —
一位心臟衰竭病史的病人，哪項評估結果暗示液體負荷過重？
Which assessment finding in a client with a history of heart failure suggests fluid overload?
- ACapillary refill time of 2 seconds毛細血管再充盈時間為 2 秒
- BPresence of an S3 heart sound✓ 正解存在 S3 心音
- CSerum potassium level of 4.0 mEq/L血清鉀濃度為 4.0 mEq/L
- DClear breath sounds on auscultation聽診時呼吸音清晰
— Explanation · 中文詳解 —
心臟衰竭（Heart Failure）病人出現液體負荷過重時，循環容量增加會導致心室舒張末期壓力上升，進而產生第三心音（S3 heart sound）。S3 心音（Ventricular Gallop）是心室過度充盈、心肌順應性下降的早期客觀體徵，反映了心臟已無法負荷過多液體。臨床護理師需敏銳捕捉此類心音變化，結合呼吸音、周邊水腫及體重監測，以評估代償機制是否失效。
An S3 heart sound is a hallmark sign of fluid overload in heart failure, indicating elevated ventricular filling pressures and decreased myocardial compliance. This gallop sound occurs when the ventricles are unable to handle the increased volume, signaling that compensatory mechanisms may be failing.