— 生理適應 · EASY · SATA —
針對早期體液容積不足的病人，護理師應預期看到哪些評估結果？（選所有適合的）
Which assessment findings should a nurse expect in a client diagnosed with early-stage fluid volume deficit? (Select all that apply.)
- ATachycardia✓ 正解心跳過速
- BIncreased urine output尿量增加
- COrthostatic hypotension✓ 正解姿勢性低血壓
- DDry mucous membranes✓ 正解口腔黏膜乾燥
- EDecreased skin turgor✓ 正解皮膚彈性減退
— Explanation · 中文詳解 —
體液容積不足（Fluid Volume Deficit, FVD）時，身體為了維持重要器官的灌流量（Perfusion），會啟動交感神經系統進行補償。心搏過速是為了維持心輸出量，姿態性低血壓則是因有效循環血量減少，導致姿勢改變時靜脈回流不足。口腔黏膜乾燥與皮膚彈性變差（Skin turgor）則是脫水導致的臨床表徵。護理師應評估這些早期徵象，以利及時補充水分，預防進展至低血容性休克。
Early signs of fluid volume deficit include tachycardia to maintain cardiac output and orthostatic hypotension due to decreased effective circulating volume. Physical assessments such as dry mucous membranes and decreased skin turgor also indicate dehydration.