— 生理適應 · MEDIUM · SATA —
一位有心衰竭病史的病人，護理師應評估哪些跡象以判斷是否有體液容積過多？（選所有適合的）
A nurse is caring for a client with a history of heart failure. Which findings indicate the client is experiencing fluid volume excess? (Select all that apply.)
- ABounding peripheral pulses✓ 正解周邊脈搏強而有力
- BPresence of crackles on lung auscultation✓ 正解聽診時出現囉音
- CDecrease in blood pressure血壓下降
- DDistended neck veins✓ 正解頸靜脈怒張
- EPresence of S3 heart sound✓ 正解出現第三心音（S3）
— Explanation · 中文詳解 —
體液容積過多（Fluid Overload）導致血管內壓力增加。臨床特徵包含：周邊脈搏強而有力（Bounding）、肺部聽診出現細濕囉音（水分積聚）、頸靜脈怒張（靜脈壓升高）以及舒張早期奔馬律（S3，心臟負荷過重）。血壓通常會升高而非降低。
Fluid volume excess manifests as increased vascular pressure, leading to bounding pulses, distended neck veins, and an S3 heart sound due to ventricular overload. Additionally, fluid accumulation in the lungs results in crackles upon auscultation, while blood pressure typically rises rather than decreases in this condition.
✦ 台美臨床差異
美國護理師在心衰竭管理上具有較高的評估自主權；台灣醫囑多較為詳細，護理人員偏向記錄觀察。