— 生理適應 · MEDIUM · MCQ —
一位肝硬化病人有腹水，下列哪項護理措施是適當的？
A client with cirrhosis has ascites. What nursing intervention is appropriate?
- ARestrict all physical movement completely完全限制所有身體活動
- BEncourage a high-sodium diet鼓勵高鈉飲食
- CIncrease fluid intake to 3L/day將水分攝取量增加至每天 3 公升
- DMeasure abdominal girth daily✓ 正解每日測量腹圍
— Explanation · 中文詳解 —
肝硬化病人因門脈高壓（Portal Hypertension）導致血管內壓力上升，同時因肝功能受損導致白蛋白合成減少，造成血漿膠體滲透壓下降，水分滲入腹腔形成腹水（Ascites）。每日測量腹圍是評估腹水增減最客觀、非侵入性的指標，能反映治療（如利尿劑、限制鈉攝取）的成效。護理師需確保測量位置固定，以維護數據的一致性。
Cirrhosis leads to portal hypertension and decreased albumin synthesis, lowering oncotic pressure and causing fluid to shift into the peritoneum (ascites). Daily abdominal girth measurement is the most objective, noninvasive way to track ascites and evaluate the response to therapy (diuretics, sodium restriction). The nurse should mark and use a consistent measurement site.