# 護理師評估一名有嘔吐與腹瀉的 2 歲幼兒。哪項發現最符合中度脫水？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393877&lang=zh-tw  
> language: zh-TW  
> subject: NCLEX-RN  
> category: BCC

## 題目

護理師評估一名有嘔吐與腹瀉的 2 歲幼兒。哪項發現最符合中度脫水？

## 選項

1. 黏膜濕潤且活動如常。
2. 哭時沒有眼淚且濕尿布變少。 **✔ 正確答案**
3. 食慾增加且體重增加。
4. 脈搏有力且皮膚潮紅。

**正確答案: 2**

## 解析

沒有眼淚與尿量減少是幼兒脫水常見發現。黏膜濕潤且活動如常較表示水分足夠。體重增加與脈搏有力不是脫水典型表現。

## 深入解析

臨床判斷
幼兒可能快速惡化，水分評估需看黏膜、眼淚、尿量、行為與灌流。

記憶重點
口乾、無淚、濕尿布變少。

## 臨床情境

實務指引
小兒脫水評估常包括尿量、眼淚、黏膜、意識狀態與灌流發現。

注意
持續嗜睡、灌流不良或無法耐受液體需要緊急處置。

## 重要概念

- **脫水** — 因攝取不足、流失過多或兩者造成的體液不足。
- **黏膜** — 用於評估乾燥程度與水分狀態的濕潤組織表面。
- **尿量** — 反映水分狀態與腎臟灌流的實用指標。

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