— 生理適應 · MEDIUM · SATA —
護理師在評估低血容積休克的病人時，預期會看到哪些臨床表現？（選所有適合的）
Which assessment findings should a nurse expect in a client experiencing hypovolemic shock? (Select all that apply.)
- ATachycardia✓ 正解心搏過速
- BNarrowed pulse pressure✓ 正解脈壓差變窄
- CBradycardia心搏過緩
- DOliguria✓ 正解少尿
- EPeripheral vasoconstriction✓ 正解周邊血管收縮
— Explanation · 中文詳解 —
休克時身體啟動交感神經代償：心跳加快（A）以維持心輸出量；血管收縮（E）維持血壓，導致脈壓變窄（B）；腎臟灌流減少導致尿量下降（D）。心跳過慢（C）在低血容積休克是晚期死亡前兆或極少見狀況，非預期表現。
Hypovolemic shock triggers sympathetic compensation, resulting in tachycardia, peripheral vasoconstriction, narrowed pulse pressure, and oliguria due to reduced renal perfusion. Bradycardia is not an expected finding in the early stages of this condition.
✦ 台美臨床差異
美國護理師常使用早期警示評分 (EWS) 介入，台灣臨床多依賴醫師醫囑啟動休克處置流程。