一位病人正處於躁症發作,過去一週體重減輕 5 磅。處理營養問題的優先護理干預為何?
A client is experiencing a manic episode and has lost 5 lbs in the last week. What is the priority nursing intervention to address nutrition?
- ASit with the client during three large meals a day.在一天三餐期間陪伴客戶用餐
- BRestrict the client to their room during meals.限制客戶在用餐期間待在房間內
- CProvide high-calorie, high-protein finger foods.✓ 正解提供高熱量、高蛋白的隨手食物
- DWait until the client's mood stabilizes to address nutrition.等待客戶情緒穩定後再處理營養問題
躁症(manic episode)發作的病人常伴有極度亢奮、活動量增加、注意力不集中和判斷力受損等症狀。這些病人往往無法靜下來好好吃飯,他們可能因為過於忙碌、興奮或分心而忽略進食,導致體重迅速減輕,正如題幹中提到的「體重減輕 5 磅」。營養不良是躁症病人常見的生理併發症,因此,護理師必須優先處理其營養問題,以維持病人的身體健康。 提供高熱量、高蛋白的隨手食物(high-calorie, high-protein finger foods)是最合適的護理干預。躁症病人難以長時間坐下用餐,需要隨時可取、方便食用的食物。這類食物不僅能提供必要的熱量和蛋白質,而且不需要餐具,也不需要病人長時間集中注意力,可以讓他們在活動中也能補充能量。這項措施直接解決了躁症病人因活動過多和注意力不集中導致的營養攝取不足問題,同時考量了其行為特點,是確保生理需求獲得滿足的優先策略。
Clients in a manic episode often experience extreme excitement, increased activity, impaired attention, and poor judgment. These clients are often unable to sit down to eat properly; they may neglect food because they are too busy, excited, or distracted, leading to rapid weight loss, as illustrated by the 5-pound weight loss in the question stem. Malnutrition is a common physiologic complication in manic clients, so the nurse must prioritize nutrition to maintain the client's physical health. Providing high-calorie, high-protein finger foods is the most appropriate intervention. Manic clients find it difficult to sit at a table for long periods and need foods that are readily available and easy to eat. Such foods provide essential calories and protein, require no utensils, and do not demand prolonged concentration, allowing the client to consume energy while moving. This intervention directly addresses the nutritional deficit caused by hyperactivity and distractibility while taking the client's behavioral characteristics into account, making it the priority strategy for meeting physiologic needs.