— 生理適應 · EASY · SATA —
護理師觀察到體液容積過負荷的病人，應包含哪些評估發現？（選所有適合的）
Which assessment findings should a nurse expect in a client with fluid volume overload? (Select all that apply.)
- ADistended neck veins✓ 正解頸靜脈怒張
- BBounding pulse✓ 正解脈搏強而有力
- CCrackles on lung auscultation✓ 正解聽診肺部有囉音
- DDecreased urine output尿量減少
- EPeripheral pitting edema✓ 正解周邊凹陷性水腫
— Explanation · 中文詳解 —
體液過負荷（Hypervolemia）表現為血管內容積過剩，導致靜脈壓升高（頸靜脈怒張）、心臟負荷增加（強脈搏）、肺部淤血（濕囉音）及組織水腫。選項 D 為脫水或腎功能衰竭的表現，非體液過負荷的典型徵象。
Fluid volume overload typically presents with distended neck veins due to increased venous pressure, bounding pulses from expanded blood volume, crackles from pulmonary congestion, and peripheral pitting edema from excess interstitial fluid.
✦ 台美臨床差異
台美臨床對於體液評估的重視程度相當，但在評估水腫時美國更強調皮膚完整性監測以防壓力性損傷。