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生理適應 · MEDIUM · SATA

護理師照護一位有中風病史且出現單側忽略的病人。護理師應實施哪些介入措施?(選所有適合的)

A nurse is caring for a client with a history of stroke who is experiencing unilateral neglect. Which interventions should the nurse implement? (Select all that apply.)

  • APlace objects within the client's visual field on the affected side✓ 正解
    將物品置於病人患側的視野範圍內
  • BEncourage the client to turn their head and scan the environment✓ 正解
    鼓勵病人轉頭並掃描環境
  • CRemind the client to touch and use their affected limb✓ 正解
    提醒病人觸碰及使用患側肢體
  • DEducate family members about the client's condition✓ 正解
    衛教家屬關於病人的狀況
  • EAllow the client to ignore the affected side to prevent frustration
    允許病人忽略患側以預防挫折感
Explanation · 中文詳解

單側忽略(Unilateral Neglect)是中風後常見的神經行為異常,特別好發於右大腦半球受損的病人。病人會喪失對患側(通常是左側)空間及身體的覺察。護理的核心目標是「重新訓練大腦對患側的關注」,透過視覺、觸覺與本體感覺的刺激,強迫病人掃描患側環境。同時,家屬衛教亦至關重要,以確保出院後居家照護的延續性。

Unilateral neglect is a common neurobehavioral disorder after stroke, particularly with right hemisphere injury. The client loses awareness of the affected side (usually the left) of space and body. The core nursing goal is to retrain the brain to attend to the affected side through visual, tactile, and proprioceptive stimulation, forcing the client to scan the affected environment. Family teaching is also critical to ensure continuity of home care after discharge.

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