— 生理適應 · HARD · SATA —
護理師照顧高血鈉病人，預期會出現下列哪些症狀？（選所有適合的）
A nurse is caring for a client with hypernatremia. Which signs should the nurse expect to assess? (Select all that apply.)
- AIntense thirst✓ 正解極度口渴
- BDry mucous membranes✓ 正解黏膜乾燥
- CPeripheral edema周邊水腫
- DDecreased level of consciousness✓ 正解意識水平下降
- EMuscle twitching✓ 正解肌肉抽搐
— Explanation · 中文詳解 —
高血鈉代表細胞外液滲透壓升高，導致細胞脫水。典型症狀包括口渴中樞受刺激（強烈口渴）、黏膜乾燥。因腦細胞脫水，病人易出現意識改變（昏睡、混亂）與神經肌肉興奮性增加（肌肉顫動、痙攣）。周邊水腫通常與低鈉或心衰竭相關，非高血鈉之典型表現。
Hypernatremia causes cellular dehydration, leading to intense thirst, dry mucous membranes, and neurological changes like decreased consciousness due to brain cell shrinkage. It also increases neuromuscular irritability, resulting in muscle twitching, whereas peripheral edema is typically associated with fluid overload rather than hypernatremia.
✦ 台美臨床差異
美台對於高血鈉之補液計算與滲透壓監測指引一致，重點皆在於矯正滲透壓速度，避免腦水腫。