— 生理適應 · EASY · MCQ —
一位病人因體液容積缺失入院。護理師預期會評估到下列哪項徵象？
A client is admitted with clinical manifestations of fluid volume deficit. Which assessment finding should the nurse expect?
- AIncreased blood pressure血壓升高
- BOrthostatic hypotension✓ 正解姿勢性低血壓
- CBounding pulse洪脈
- DDistended neck veins頸靜脈怒張
— Explanation · 中文詳解 —
體液容積缺失（Fluid Volume Deficit）的核心病理生理變化是有效循環血量不足。當病人從臥位改變為坐位或站位時，由於血容量不足，心臟無法維持足夠的輸出量，導致血壓下降，這就是姿勢性低血壓（Orthostatic Hypotension）。選項 D、A、C 均為體液過多的徵象，例如頸靜脈怒張和洪脈通常代表前負荷過高。護理師應以此評估結果作為優先的安全指導依據，例如提醒病人起身動作應緩慢，以防暈倒跌倒。
Orthostatic hypotension is a key assessment finding in fluid volume deficit because decreased circulating volume impairs the heart's ability to maintain blood pressure upon position changes. Signs such as bounding pulses, distended neck veins, or increased blood pressure are indicative of fluid volume excess rather than deficit.
✦ 台美臨床差異
美國 NCLEX 強調姿勢性低血壓的定義為收縮壓下降超過 20 mmHg；台灣臨床實務中，護理師通常會測量平躺與站立血壓，並將此數據作為評估點滴滴速與口服補充量的依據。