— 基本照護與舒適 · MEDIUM · SATA —
護理師評估一位病人是否有體液流失（脫水），預期會發現哪些徵兆？（選所有適合的）
A nurse is assessing a client for signs of fluid volume deficit. Which findings are expected? (Select all that apply.)
- ATachycardia✓ 正解心搏過速
- BIncreased urine output尿液排出量增加
- CPoor skin turgor✓ 正解皮膚彈性差
- DDry mucous membranes✓ 正解黏膜乾燥
- EHypotension✓ 正解低血壓
— Explanation · 中文詳解 —
體液流失（Fluid Volume Deficit）導致循環血量減少，身體會產生一系列代償與病理反應。心跳加速（Tachycardia）是為了維持心輸出量（Cardiac Output）的早期代償；低血壓（Hypotension）則發生在脫水較嚴重時。皮膚彈性變差（Poor skin turgor）與黏膜乾燥（Dry mucous membranes）是反映組織脫水的典型身體徵象。
Fluid volume deficit causes decreased circulating blood volume, leading to tachycardia as an early compensatory mechanism to maintain cardiac output. As dehydration progresses, clients exhibit poor skin turgor, dry mucous membranes, and hypotension due to reduced tissue hydration and vascular volume.