— 生理適應 · MEDIUM · SATA —
護理師評估一位疑似體液過載的病人，下列哪些發現支持此診斷？（選所有適合的）
A nurse is assessing a client with signs of fluid volume overload. Which findings support this diagnosis? (Select all that apply.)
- ABounding peripheral pulses✓ 正解周圍脈搏強勁
- BCrackles on lung auscultation✓ 正解肺部聽診有爆裂音
- CDecreased blood pressure血壓下降
- DDistended neck veins✓ 正解頸靜脈怒張
- EPeripheral pitting edema✓ 正解周邊凹陷性水腫
— Explanation · 中文詳解 —
體液過載（Fluid Overload）導致血管內壓力增加。臨床特徵包括：強而有力的搏動（bounding pulses）、肺部積水導致囉音（crackles）、靜脈回流受阻導致頸靜脈怒張（JVD）及下肢凹陷性水腫。C（血壓下降）通常與體液不足相關，過載時血壓常表現為正常或升高。
Findings supporting fluid volume overload include bounding peripheral pulses, crackles on lung auscultation, distended neck veins, and peripheral pitting edema due to increased hydrostatic pressure and venous return. Blood pressure typically increases or remains stable rather than decreasing, which would suggest hypovolemia.
✦ 台美臨床差異
美國護理評估（Assessment）是自主權限的核心，發現異常可直接通知醫師並啟動相關護理措施，台灣則受限較多。