一位加護病房護理師正在評估一名因腦腫瘤剛完成開顱手術的 40 歲男性。在過去一小時內，病患的尿量突然暴增至 850 mL 且極度稀薄，同時血壓下降至 92/58 mmHg。哪項護理行動為首要的臨床優先？
An intensive care nurse evaluates a 40-year-old male post-craniotomy for a massive brain tumor. Over the last hour, the client’s urine output has surged suddenly to 850 mL of extremely dilute, pale urine, while his blood pressure has dropped to 92/58 mmHg. Which nursing action takes the utmost immediate clinical priority?
- AAdminister a rigorous IV fluid bolus promptly and urgently notify the physician.✓ 正解迅速給予大量靜脈輸液衝刺，並立即通知醫師。
- BIncrease the mechanical ventilator oxygen fraction significantly to combat shock.大幅增加機械通氣的氧氣濃度以對抗休克。
- CPerform a comprehensive deep neurological pupil assessment exclusively.僅進行全面性的深層神經學瞳孔評估。
- DDocument the diuresis output as an expected clearing response.將多尿量記錄為預期的清除反應。
本題測驗神經外科急症的優先順序判斷 (Prioritization / DI crisis)。開顱手術後腦下垂體極易受損，引發致命『尿崩症 (DI)』。DI 的特徵是抗利尿激素停止分泌，病患會在一小時內狂拉幾千 C.C 像水的清澈尿液。這會瞬間導致低血容積休克死亡。護理師絕對第一優先是立刻給予靜脈輸液把水分強制補回來，並通知醫師開立抗利尿激素藥物 (Desmopressin) 來止尿。選項 C 瞳孔檢查是次要的，病患正死於缺水休克。
This question tests prioritization in a neurosurgical emergency (DI crisis). Post-craniotomy, the pituitary is highly vulnerable, predisposing to lethal diabetes insipidus (DI). DI is characterized by sudden cessation of ADH secretion; the client produces thousands of mL of dilute clear urine within an hour, rapidly causing hypovolemic shock and death. The nurse's absolute first priority is to immediately administer IV fluids to forcibly replace volume and notify the physician for desmopressin (antidiuretic medication) orders. Option C (pupil check) is secondary—the patient is dying from volume-depletion shock.
看到術後狂尿，毫無疑問發生 DI，馬上補水跟打 DDAVP。