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心理社會完整性 · MEDIUM · SATA

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
Explanation · 中文詳解

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.

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