— 安全與感染控制 · HARD · SATA —
護理師評估一位疑似全身性感染的病人。下列哪些發現代表嚴重敗血症（Severe Sepsis）？（選所有適合的）
A nurse is evaluating a client for signs of systemic infection. Which findings are indicative of severe sepsis? (Select all that apply.)
- AHypotension✓ 正解低血壓
- BAltered mental status✓ 正解精神狀態改變
- CIncreased urine output尿量增加
- DElevated lactate levels✓ 正解乳酸值升高
- EBradycardia心搏過緩
— Explanation · 中文詳解 —
嚴重敗血症（Severe Sepsis）代表感染已引起器官功能不全（Organ Dysfunction）。臨床特徵為低血壓（灌流不足）、意識改變（缺氧或代謝異常）及高乳酸血症（組織無氧代謝標誌）。敗血症病人常伴隨心搏過速、呼吸過快及少尿。護理師需密切監測生命徵象與實驗室數值，並協助啟動敗血症急救套組（Sepsis Bundle）。
Severe sepsis is characterized by organ dysfunction resulting from infection, manifesting as hypotension due to poor perfusion, altered mental status from cerebral hypoxia, and elevated lactate levels indicating anaerobic metabolism. These findings signal a medical emergency requiring prompt recognition and initiation of sepsis protocols.