— 照護管理 · MEDIUM · MCQ —
護理師照顧一位有心衰竭病史的病人，哪些發現應優先回報給醫師？
A nurse is caring for a client with a history of heart failure. Which findings should the nurse prioritize reporting to the physician?
- AA slight increase in appetite食慾略微增加
- BMild peripheral edema輕微周邊水腫
- CA weight gain of 3 lbs in 24 hours✓ 正解24小時內體重增加 3 磅
- DOccasional sleeping in a chair偶爾坐在椅子上睡覺
— Explanation · 中文詳解 —
心衰竭病人的體重監測是評估液體滯留最敏感的指標。24 小時內體重增加超過 2-3 lbs（約 1-1.5 公斤），暗示體內水分滯留失控，極可能導致肺水腫或急性心衰竭失代償，需立即介入治療或調整利尿劑劑量。
A weight gain of 3 pounds in 24 hours is a critical sign of rapid fluid retention and potential acute decompensation in heart failure, requiring immediate physician notification. While mild edema and orthopnea are expected chronic symptoms, sudden weight gain signals worsening fluid overload that needs urgent treatment.
✦ 台美臨床差異
美台對心衰竭病人的「每日量體重」衛教一致，皆為門診追蹤與住院照護核心。