— 降低風險 · HARD · SATA —
護理師評估一位病人是否有內出血徵兆。下列哪些是關鍵發現？（選所有適合的）
A nurse is assessing a client for signs of internal bleeding. What are key findings? (Select all that apply.)
- ATachycardia✓ 正解心搏過速
- BHypotension✓ 正解低血壓
- CDizziness or syncope✓ 正解頭暈或暈厥
- DCool, clammy skin✓ 正解皮膚濕冷
- EAbdominal rigidity✓ 正解腹部僵硬
— Explanation · 中文詳解 —
內出血（Internal bleeding）會導致循環血量減少，引發低血容性休克。初期身體會透過交感神經代償導致心搏過速（Tachycardia），隨後血壓下降（Hypotension）。灌流不足會導致末梢濕冷與意識改變（頭暈、暈厥）。若出血發生在腹腔，會刺激腹膜導致腹部僵硬（Rigidity），這是極需緊急處理的徵象。
Key findings of internal bleeding include tachycardia, hypotension, dizziness or syncope, cool clammy skin, and abdominal rigidity. Tachycardia is an early compensatory response to falling blood volume, while hypotension indicates late-stage shock. Decreased cerebral perfusion causes dizziness, peripheral vasoconstriction leads to cool skin, and abdominal rigidity suggests blood irritating the peritoneum.