— 生理適應 · MEDIUM · SATA —
低血容積性休克病患可能出現哪些臨床症狀？（選所有適合的）
Which signs and symptoms should the nurse expect in a client with hypovolemic shock? (Select all that apply.)
- ATachycardia✓ 正解心跳過速
- BDecreased urine output✓ 正解尿液排出量減少
- CHypertension高血壓
- DCool, clammy skin✓ 正解皮膚冰冷且潮濕
- EConfusion or agitation✓ 正解意識混亂或躁動
— Explanation · 中文詳解 —
低血容積性休克導致組織灌流不足。身體透過交感神經代償引起心跳過速 (Tachycardia)；腎血流減少導致尿量下降；血液重分配導致皮膚冰冷與濕黏；腦部灌流不足導致精神狀態改變（混亂）。C 選項錯誤，低血容積會導致低血壓，而非高血壓。
Hypovolemic shock triggers compensatory mechanisms including tachycardia to maintain cardiac output and peripheral vasoconstriction, resulting in cool, clammy skin. Reduced renal perfusion leads to decreased urine output, while cerebral hypoxia causes confusion or agitation. Hypertension is incorrect, as shock typically presents with hypotension due to volume loss.
✦ 台美臨床差異
美台對休克的定義與評估標準一致，重點都在於維持臟器灌流。