一位處於躁期發作的病人。護理師應將哪些護理措施納入計畫?(選所有適合的)
A client is experiencing a manic episode. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AProvide high-calorie finger foods✓ 正解提供高熱量的手指食物
- BEncourage long, complex group activities鼓勵參與長而複雜的團體活動
- CMaintain a low-stimulation environment✓ 正解維持低刺激環境
- DSet firm, consistent limits on behavior✓ 正解對行為設定堅定且一致的界線
- EAllow the client to dominate group discussions允許個案主導團體討論
躁期發作(Manic Episode)是雙相情感障礙(Bipolar Disorder)的特徵之一,病人會表現出情緒高漲、易怒、活動量異常增加、精力旺盛、睡眠需求減少、說話快速、思維奔逸、注意力分散及判斷力受損等症狀。在躁期,病人常因活動過度而忽略飲食和休息,可能出現脫水和營養不良,並因衝動行為而面臨安全風險。 護理師在照護躁期病人時,首要目標是確保病人的安全,並穩定其生理狀態。由於病人精力過剩且注意力不集中,護理措施應簡潔、直接,並提供一個結構化、低刺激的環境。同時,由於躁期病人可能缺乏病識感,護理師需要設定明確且一致的行為界線,以管理其衝動和不當行為。這些介入旨在幫助病人從混亂狀態中恢復,並預防自我傷害或傷害他人。
Interventions should include providing high-calorie finger foods to accommodate the client's inability to sit still, maintaining a low-stimulation environment to reduce agitation, and setting firm, consistent limits to ensure safety. These measures address the client's hyperactivity, potential neglect of self-care, and risk of impulsive behavior.