一位處於躁鬱症躁期的個案在走廊來回踱步,並大聲發表誇大的言論。護理師應採取哪些措施?(選所有適合的)
A client in the manic phase of bipolar disorder is pacing the halls and making loud, grandiose statements. Which actions should the nurse take? (Select all that apply.)
- APlace the client in a quiet, low-stimulation environment✓ 正解將客戶安置於安靜、低刺激的環境
- BSpeak with a soft, calm, and firm voice✓ 正解以柔和、平靜且堅定的語氣說話
- CConfront the client about the inaccuracy of their statements指出客戶言論的不實之處並予以對質
- DProvide high-protein finger foods✓ 正解提供高蛋白的手指食物
- ELimit the amount of time the client spends with other patients✓ 正解限制客戶與其他病患相處的時間
躁期個案容易受過度刺激影響,環境控制至關重要。使用低刺激環境並限制與他人互動可減少激動。溝通時應語氣平靜堅定,不可與其辯論誇大內容(辯論會增加對立)。由於躁期個案活動量大,提供容易攝取的指狀高蛋白食物可滿足能量需求並維持營養。
Clients in the manic phase are easily overstimulated, so environmental control is essential. Providing a low-stimulation environment and limiting interaction with others reduces agitation. Communication should use a calm, firm tone, and the nurse must not argue about the grandiose content (which would increase opposition). Because clients in the manic phase have a high level of activity, providing easy-to-consume high-protein finger foods helps meet energy needs and maintain nutrition.
美國護理師在病房管理中會嚴格執行環境減壓,台灣病房因空間擁擠,對躁動病人多以給予鎮靜藥物為主。