— 生理適應 · MEDIUM · SATA —
下列哪些評估結果顯示病人可能有體液容積缺失？（選所有適合的）
Which assessment findings indicate potential fluid volume deficit? (Select all that apply.)
- ATachycardia✓ 正解心跳過速
- BDry mucous membranes✓ 正解黏膜乾燥
- CDistended neck veins頸靜脈怒張
- DDecreased urine output✓ 正解尿量減少
- EHypotension✓ 正解低血壓
— Explanation · 中文詳解 —
體液容積缺失（fluid volume deficit）的臨床表現：A. 心跳加快——交感神經代償維持心輸出量；B. 黏膜乾燥——體液不足導致；D. 尿量減少（oliguria）——腎血流不足；E. 其他常見徵象（如皮膚彈性差、低血壓、體重下降）。錯誤：C. 頸靜脈怒張（distended neck veins）為體液容積過多的表現，與體液缺失相反。
Signs of fluid volume deficit include tachycardia as a compensatory mechanism for decreased stroke volume, dry mucous membranes due to dehydration, decreased urine output as the kidneys conserve fluid, and hypotension resulting from significant volume loss. Distended neck veins are an indicator of fluid volume excess, not deficit, and thus are not associated with dehydration.
✦ 台美臨床差異
台美均強調病史與理學檢查的配合，台灣護理師在監測 I/O 變化上常負有極重責任。