— 生理適應 · MEDIUM · SATA —
護理師評估一位病人是否有低血容性休克徵象。下列哪些臨床表現是預期會發現的？（選所有適合的）
A nurse is evaluating a client for signs of hypovolemic shock. Which clinical findings should the nurse expect? (Select all that apply.)
- ATachycardia✓ 正解心動過速
- BDecreased urine output✓ 正解尿量減少
- CHypertension高血壓
- DCool, clammy skin✓ 正解皮膚濕冷
- EConfusion or agitation✓ 正解意識混亂或煩躁不安
— Explanation · 中文詳解 —
低血容性休克因血量減少，交感神經代償導致心跳加速（Tachycardia）與血管收縮。腎臟灌流不足造成尿量減少，組織灌流差導致皮膚濕冷且出現代謝性酸中毒或缺氧造成的意識改變。高血壓是錯誤的，休克時應呈現低血壓。
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 hypoperfusion causes confusion or agitation; hypertension is not expected as shock typically presents with hypotension.
✦ 台美臨床差異
美台對休克病人的監測標準一致，但美國護理師常依據 EARLY GOAL-DIRECTED THERAPY 進行更積極的液體復甦。