— 生理適應 · MEDIUM · MCQ —
一位嚴重燒傷病人正接受大量靜脈輸液。哪項發現表示病人出現體液過多？
A client with severe burns is receiving a large volume of intravenous fluids. Which finding indicates that the client is experiencing fluid overload?
- AIncreased urine output尿液排出量增加
- BJugular venous distention✓ 正解頸靜脈怒張
- CDecreased heart rate心率減慢
- DDecreased blood pressure血壓下降
— Explanation · 中文詳解 —
嚴重燒傷病人在復甦期因大量輸液可能導致體液過多 (fluid overload)。頸靜脈怒張 (Jugular venous distention, JVD) 是中心靜脈壓 (CVP) 升高的直接體徵，反映心臟無法負荷回流的血量，導致靜脈系統鬱血。在 NCLEX 考試中，處理體液失衡問題應優先評估心肺徵象，JVD、肺部囉音 (crackles) 及呼吸困難皆為體液過多的關鍵臨床指標。
Jugular venous distention is a key clinical sign of fluid overload, indicating increased central venous pressure and the heart's inability to handle the returned blood volume. In burn patients receiving aggressive fluid resuscitation, monitoring for signs of cardiovascular compromise like JVD, crackles, or dyspnea is critical to prevent complications.