— 生理適應 · MEDIUM · MCQ —
護理師正在照護一位慢性心臟衰竭病人。哪項評估發現表明液體過量正在惡化？
A nurse is caring for a client with chronic heart failure. Which assessment finding indicates worsening fluid overload?
- ADecreased heart rate心率降低
- BWeight loss of 1 kg overnight一夜間體重減輕 1 公斤
- CDevelopment of pitting edema in the lower extremities✓ 正解下肢出現壓痕性水腫
- DClient reports increased energy levels個案報告精力增加
— Explanation · 中文詳解 —
心臟衰竭導致液體滯留，壓迫性水腫（pitting edema）是體液過量的典型表現，尤其在腳踝、小腿。體重增加（非減輕）也表示體液滯留。心臟衰竭通常伴隨心率增加（代償），故心率下降不一定是改善。能量增加表示狀況好轉。
Worsening fluid overload in heart failure is indicated by signs of volume excess, such as the development of pitting edema in the lower extremities. Other indicators include weight gain rather than loss, as retained fluid increases body mass. Conversely, decreased heart rate, weight loss, and increased energy levels typically suggest improved cardiac function or fluid loss, not deterioration.
✦ 台美臨床差異
美國的護理師會定期指導病人居家體重監測與水腫評估，並建立追蹤機制；台灣也重視此部分，但病人居家監測的精準度與回報意願影響甚鉅。