— 生理適應 · MEDIUM · SATA —
護理師正在照護一位心臟衰竭病人。哪些評估發現最能指示有液體過量？（選所有適合的）
A nurse is caring for a client with heart failure. Which assessment findings are MOST indicative of fluid overload? (Select all that apply.)
- AJugular venous distention (JVD)✓ 正解頸靜脈怒張 (JVD)
- BCrackles in the lung bases✓ 正解肺底部囉音
- CDecreased breath sounds呼吸音減弱
- DPeripheral edema✓ 正解周邊水腫
- EWeight loss體重減輕
— Explanation · 中文詳解 —
液體過量的典型徵象包括：頸靜脈怒張（JVD）、肺底囉音（crackles）、周邊水腫（peripheral edema）。體重增加是液體滯留的指標，而非減輕。呼吸音減弱可能與其他因素有關，或表示肺部過度擴張，但囉音更直接反映肺部積液。
Jugular venous distention, crackles in the lung bases, and peripheral edema are key indicators of fluid overload in heart failure patients, reflecting increased central venous pressure and pulmonary congestion. Weight loss suggests fluid deficit rather than overload, and decreased breath sounds are not a primary sign of fluid accumulation compared to crackles.
✦ 台美臨床差異
美國的護理師在評估心衰竭時，會系統性地評估 JVD、肺部聽診與水腫；台灣的照護也包含這些項目，但病人對居家體重監測的配合度是關鍵。