— 生理適應 · HARD · SATA —
一位心衰竭病人，哪些發現暗示病人可能發生心包填塞（Cardiac tamponade）？（選所有適合的）
A nurse is caring for a client with a history of heart failure. Which findings suggest that the client may have developed cardiac tamponade? (Select all that apply.)
- AMuffled heart sounds✓ 正解心音模糊
- BJugular vein distention (JVD)✓ 正解頸靜脈怒張 (JVD)
- CHypotension✓ 正解低血壓
- DBounding pulse脈搏強勁
- EBradycardia心動過緩
— Explanation · 中文詳解 —
心包填塞經典表現為 Beck's Triad：心音模糊（Muffled heart sounds）、頸靜脈怒張（JVD）、低血壓（Hypotension）。這是因為液體積聚限制心臟充盈。跳躍式脈搏與過慢心跳非此病典型徵象。
Cardiac tamponade is classically identified by Beck's triad: muffled heart sounds due to fluid accumulation, jugular vein distention from impaired venous return, and hypotension resulting from reduced cardiac output. These signs reflect the heart's restricted filling capacity caused by pericardial fluid compression.
✦ 台美臨床差異
兩地對於 Beck's Triad 的教學皆視為心導管或術後併發症的高級護理知識。