— 生理適應 · EASY · MCQ —
護理師照護一位體液容積不足的病人，下列何種評估結果最能佐證此診斷？
A nurse is caring for a client diagnosed with fluid volume deficit. Which assessment finding is most indicative of this condition?
- AIncreased capillary refill time✓ 正解毛細血管再充盈時間延長
- BBounding peripheral pulses周邊脈搏強勁
- CDistended neck veins頸靜脈怒張
- DDecreased serum osmolality血清滲透壓降低
— Explanation · 中文詳解 —
體液容積不足（Fluid volume deficit）導致組織灌流下降，身體會啟動代償機制，將血液優先供給重要器官，導致末梢血管收縮。微血管回流時間（Capillary refill time）延長（大於 3 秒）是評估末梢灌流不足的敏感指標。頸靜脈怒張與脈搏強勁（Bounding pulses）均是體液過多（Fluid volume excess）的徵象。血清滲透壓下降通常與水分過多導致的稀釋有關，與體液不足導致的濃縮表現相反。
Increased capillary refill time is the most indicative finding of fluid volume deficit, as reduced perfusion triggers compensatory vasoconstriction in the extremities. Other options such as bounding pulses, distended neck veins, and decreased serum osmolality are signs of fluid volume excess or incorrect physiological responses.