— 生理適應 · HARD · MCQ —
一位閉合性頭部外傷病人併發尿崩症。哪項護理措施為優先？
A client with a closed head injury has developed diabetes insipidus. Which nursing intervention is priority?
- AEncourage a high-protein diet鼓勵攝取高蛋白飲食
- BMonitor urine specific gravity✓ 正解監測尿液比重
- CAdminister diuretics給予利尿劑
- DRestrict fluid intake限制液體攝取量
— Explanation · 中文詳解 —
尿崩症病人因抗利尿激素不足，會排出大量低比重尿液（Polyuria），導致嚴重脫水。監測尿比重（Urine specific gravity）是評估病情嚴重程度、監測藥物效果的關鍵指標。利尿劑會加重脫水，限水則會導致高血鈉。
Clients with diabetes insipidus lack antidiuretic hormone and excrete large amounts of dilute urine (polyuria), leading to severe dehydration. Monitoring urine specific gravity is the key indicator for assessing severity and the effect of treatment. Diuretics would worsen dehydration, and fluid restriction would cause hypernatremia.
✦ 台美臨床差異
美台皆強調嚴密紀錄 I/O，但在病情不穩時，美國護理師常執行更頻繁的尿比重測量。