— 基本照護與舒適 · MEDIUM · SATA —
哪些評估結果顯示病人正處於體液容積缺失（脫水）狀態？（選所有適合的）
Which assessment findings would indicate that a client is experiencing fluid volume deficit? (Select all that apply.)
- AIncreased skin turgor皮膚彈性增加
- BOrthostatic hypotension✓ 正解姿勢性低血壓
- CFlat neck veins when supine✓ 正解仰臥時頸靜脈扁平
- DTachycardia✓ 正解心搏過速
- EBounding peripheral pulses周邊脈搏強而有力
— Explanation · 中文詳解 —
體液缺失特徵：姿勢性低血壓（B）與心跳過快（D）是補償機制；平臥時頸靜脈塌陷（C）反映中心靜脈壓低。A 錯誤：脫水時皮膚彈性會「降低」（Decreased turgor/tenting），而非增加。E 錯誤：跳躍脈（Bounding pulse）是體液過多（Fluid overload）的徵兆，脫水者脈搏通常微弱（Weak/thready）。
Orthostatic hypotension, flat neck veins when supine, and tachycardia are key indicators of fluid volume deficit due to compensatory mechanisms and reduced intravascular volume. Increased skin turgor is incorrect because dehydration causes decreased turgor, while bounding pulses are associated with fluid volume excess.
✦ 台美臨床差異
美國 NCLEX 喜歡考老人脫水的非典型症狀（如意識混亂）；台灣臨床常以點滴輸注速率評估作為重點。