— 照護管理 · MEDIUM · MCQ —
失智症病患出現下列哪種跡象時，護理師應立即通知醫師？
Which of the following findings in a client with a history of dementia should the nurse report to the provider immediately?
- AForgetting the names of family members.忘記家人名字
- BDifficulty performing familiar household tasks.執行熟悉家務任務困難
- CA sudden onset of extreme agitation and disorientation.✓ 正解突然出現極度煩躁和定向力障礙
- DIncreased confusion during the evening hours.傍晚時分意識混亂加重
— Explanation · 中文詳解 —
失智症通常是慢性漸進的退化。若突然出現情緒激動或定向力缺失，強烈暗示譫妄（Delirium）的發生，常見於感染或藥物副作用。此種急性改變需要立即醫療評估以找出潛在病因，而其他選項如夜間混亂或記憶退化，多為失智症病程的常見表現。
Dementia is usually a chronic, gradually progressive deterioration. A sudden onset of agitation or disorientation strongly suggests delirium, which is often caused by infection or medication side effects. Such acute changes require immediate medical evaluation to identify the underlying cause. Other options such as evening confusion or memory decline are common manifestations of the dementia disease course.
✦ 台美臨床差異
美國護理師常利用評估工具（如 CAM）區分譫妄與失智，台灣亦推廣此概念。