— 降低風險 · HARD · SATA —
評估低血容性休克病人時，下列哪些發現應優先關注？（選所有適合的）
A nurse is assessing a client for signs of hypovolemic shock. Which of the following findings should the nurse prioritize? (Select all that apply.)
- ATachycardia✓ 正解心搏過速
- BIncreased pulse pressure脈壓增加
- COliguria✓ 正解少尿
- DRestlessness or confusion✓ 正解煩躁不安或意識混亂
- EHypotension✓ 正解低血壓
— Explanation · 中文詳解 —
低血容性休克（Hypovolemic shock）早期表現為代償性反應，如心搏過速（Tachycardia）以維持心輸出量。隨著灌流不足，腎臟血流量減少導致少尿（Oliguria）。腦部灌流下降導致病人出現焦慮、混亂（Restlessness/Confusion）。晚期代償失敗則出現低血壓（Hypotension）。脈壓變窄（而非變寬）才是休克的典型特徵。
Hypovolemic shock triggers compensatory mechanisms like tachycardia to maintain cardiac output and oliguria due to decreased renal perfusion. As compensation fails, clients experience restlessness from cerebral hypoperfusion and late-stage hypotension.