— 生理適應 · EASY · MCQ —
護理師評估一位體液容積過多的病人，應預期觀察到下列哪項臨床發現？
A nurse is assessing a client with fluid volume excess. Which clinical finding should the nurse expect to observe?
- ABounding pulse✓ 正解脈搏強而有力
- BConcentrated urine尿液濃縮
- CPoor skin turgor皮膚彈性差
- DDecreased blood pressure血壓下降
— Explanation · 中文詳解 —
體液容積過多（Fluid Volume Excess）會增加血管內壓力，導致心搏輸出量增加，出現洪大且強力的脈搏。其他選項皆為脫水或體液不足的臨床特徵，例如皮膚彈性變差、血壓下降與尿液濃縮，與容積過多之病理表現相反。
Fluid volume excess increases intravascular pressure and cardiac output, resulting in a bounding pulse. Other options such as concentrated urine, poor skin turgor, and decreased blood pressure are signs of fluid volume deficit or dehydration, not excess.
✦ 台美臨床差異
台美臨床評估體液狀況皆依賴聽診（肺部囉音）與觸診，但美國護理師對體液監測的權責範圍較具獨立性。