# 將每個評估趨勢拖曳至其最能支持的心衰竭灌注狀態。 > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=395501&lang=zh-tw > language: zh-TW > subject: Illness Management > category: PA ## 題目 將每個評估趨勢拖曳至其最能支持的心衰竭灌注狀態。 **1.** 新出現的端坐呼吸伴瀰漫性囉音且氧氣需求增加 Select a category Inadequate perfusion Worsening congestion Improving response to treatment **2.** 頸靜脈怒張伴 2 天內體重增加 2.3 kg Select a category Inadequate perfusion Worsening congestion Improving response to treatment **3.** 四肢冰冷斑駁伴尿量 15 mL/hr Select a category Inadequate perfusion Worsening congestion Improving response to treatment **4.** 新出現的意識混亂伴脈搏微弱且脈壓變窄 Select a category Inadequate perfusion Worsening congestion Improving response to treatment **5.** 呼吸困難減輕伴氧氣需求降低且囉音改善 Select a category Inadequate perfusion Worsening congestion Improving response to treatment **6.** 尿量增加且四肢變溫暖伴脈搏增強 Select a category Inadequate perfusion Worsening congestion Improving response to treatment ## 解析 端坐呼吸、囉音、頸靜脈怒張與快速體重增加支持充血惡化。四肢冰冷、寡尿、意識改變與脈壓變窄提示灌注不足。當整體病程一致時，氧氣需求降低與呼吸困難減輕，加上尿量改善與周邊溫暖，支持病情改善。 ## 深入解析 快速解答 濕性表徵表示充血；冷性表徵表示灌注不良；呼吸改善、尿量增加與四肢溫暖表示治療反應。 為何此為正確 心衰竭嚴重度無法僅由水腫判斷。指引建議評估充血嚴重度、灌注充足性、誘發因素及整體病程，以引導分級與治療。 NCLEX 決策原則 依趨勢群集而非單一孤立數值判斷。呼吸窘迫惡化或器官低灌注徵象應立即升級處置。References 12022 AHA/ACC/HFSA Heart Failure Guideline 2AHA Heart Failure Guideline Hub ## 臨床情境 代償失調心衰竭病程 一名成人因急性代償失調心衰竭住院。護理師重新評估充血與器官灌注，以判斷惡化或對治療的反應。每個趨勢僅有一個最適類別。 ## 重要概念 - **充血** — 血管內與間質容積過多，產生端坐呼吸、囉音、頸靜脈怒張或水腫等表徵。 - **低灌注** — 器官血流不足，由四肢冰冷、尿量減少、意識改變或脈搏微弱所提示。 - **臨床病程** — 重複評估之症狀、身體檢查發現、排出量與治療反應的變化方向。 ## 相同主題題目 - [A client with suspected urosepsis has a temperature of 39.1 C, blood pressure 86/48 mm Hg,…](https://mymerci.kr/pages/nclex_q.php?qn_id=393666&lang=zh-tw) - [A client with diabetic ketoacidosis is prescribed IV insulin. The potassium level is 2.9 m…](https://mymerci.kr/pages/nclex_q.php?qn_id=394074&lang=zh-tw) - [A client with adrenal insufficiency has vomiting, severe weakness, blood pressure 78/42 mm…](https://mymerci.kr/pages/nclex_q.php?qn_id=394151&lang=zh-tw) - [Place the actions in order for an adult with probable sepsis, a mean arterial pressure of …](https://mymerci.kr/pages/nclex_q.php?qn_id=394886&lang=zh-tw) - [A client has a potassium level of 6.9 mEq/L and a widened QRS complex. For each finding or…](https://mymerci.kr/pages/nclex_q.php?qn_id=395582&lang=zh-tw) - [A client with suspected infection has temperature 39.2 C, heart rate 126/min, blood pressu…](https://mymerci.kr/pages/nclex_q.php?qn_id=397263&lang=zh-tw) - [A client develops stridor, facial swelling, and hypotension after receiving an antibiotic.…](https://mymerci.kr/pages/nclex_q.php?qn_id=397318&lang=zh-tw) - [A client with type 1 diabetes received the morning insulin dose, and the breakfast tray wa…](https://mymerci.kr/pages/nclex_q.php?qn_id=522675&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=395501&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=395501&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=395501&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=395501&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=395501&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_