— 降低風險 · EASY · MCQ —
護理師為一位老年病人進行身體評估，哪項發現應識別為潛在的脫水徵兆？
A nurse is performing a physical assessment on an older adult. Which clinical finding should the nurse recognize as a potential sign of dehydration?
- ABradycardia心動過緩
- BIncreased skin turgor皮膚彈性增加
- CPeripheral edema周邊水腫
- DConfusion✓ 正解意識混亂
— Explanation · 中文詳解 —
老年人對缺水反應較不敏感，初期徵兆常非顯著的皮膚彈性變差，而是神經學改變如混亂或認知功能異常。外周水腫通常與液體超載相關，脫水時通常伴隨代償性的心跳過速，而非心搏過緩。皮膚彈性在老年人因皮下脂肪減少而不準確。
In older adults, confusion or acute changes in mental status are often early indicators of dehydration, whereas skin turgor is unreliable due to decreased elasticity. Dehydration typically causes tachycardia rather than bradycardia, and peripheral edema suggests fluid overload rather than depletion.
✦ 台美臨床差異
美國護理界強調脫水與意識改變的關聯性以防止跌倒，台灣臨床更常藉由每日監測輸出入量與體重來評估。