— 生理適應 · MEDIUM · SATA —
一位病患出現液體容積過量的徵兆，護理師預期會發現下列哪些症狀？（選所有適合的）
A client presents with signs of fluid volume overload. Which findings should the nurse expect to see? (Select all that apply.)
- ABounding pulse✓ 正解強而有力的脈搏
- BDistended neck veins✓ 正解頸靜脈怒張
- CCrackles in the lungs✓ 正解肺部囉音
- DIncreased urine specific gravity增加的尿液比重
- EPeripheral edema✓ 正解周邊水腫
— Explanation · 中文詳解 —
液體容積過量（Fluid Volume Overload/Hypervolemia）會導致血管內液體增加，引發一系列生理變化。臨床表現包括：血管壓力升高（強而有力的脈搏）、靜脈回流受阻（頸靜脈怒張）、肺部液體淤積（濕囉音）以及組織間隙水腫（周邊水腫）。尿比重在過量時通常會因尿液稀釋而下降，而非上升。護理師需監測這些指標以評估治療成效。
Fluid volume overload increases intravascular volume, leading to a bounding pulse, distended neck veins from venous congestion, crackles due to pulmonary fluid accumulation, and peripheral edema from increased capillary hydrostatic pressure. Urine specific gravity typically decreases rather than increases because the excess fluid dilutes the urine.