— 生理適應 · EASY · SATA —
護理師評估液體容積過載的病患，預期會出現哪些症狀？（選所有適合的）
A nurse is assessing a client with fluid volume overload. Which findings should the nurse expect? (Select all that apply.)
- ABounding pulse✓ 正解脈搏強而有力
- BDistended neck veins✓ 正解頸靜脈怒張
- CDecreased blood pressure血壓下降
- DCrackles in lung fields✓ 正解肺野出現囉音
- EWeight loss體重減輕
— Explanation · 中文詳解 —
液體容積過載（Fluid Volume Overload/Hypervolemia）是指體內水分與鈉離子滯留，導致血管內容積擴張。臨床評估時，應關注循環系統負荷過重及體液滲漏至組織間隙的徵象。正確答案為脈搏強而有力、頸靜脈怒張及肺部囉音，這些均反映了循環壓力增加與肺水腫風險。低血壓與體重減輕則為脫水或低血容積的典型表徵。
Fluid volume overload results in increased circulatory pressure and fluid shifting into interstitial spaces, leading to bounding pulses, distended neck veins, and pulmonary crackles. These findings reflect the heart's inability to handle the excess volume and subsequent pulmonary edema. Low blood pressure and weight loss are indicative of fluid volume deficit, not overload.