護理師照顧一位處於躁狂發作期的病人,應在護理計畫中包含哪些措施?(選所有適合的)
A nurse is managing a client who is experiencing a manic episode. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AProvide a structured, low-stimulus environment✓ 正解提供結構化、低刺激的環境
- BOffer frequent, high-calorie finger foods✓ 正解提供頻繁的高熱量手指食物
- CAllow the client to engage in high-energy group activities允許病人參與高能量的團體活動
- DEncourage the client to sleep whenever they feel tired鼓勵病人感到疲倦時隨時睡覺
- ELimit social interactions until the client is more stable✓ 正解在病人較穩定之前限制社交互動
躁狂發作(Manic episode)的核心護理目標在於降低病人的心理激越感、維持生理需求及確保安全。由於病人處於高能量、易分心且衝動的狀態,環境必須結構化(Structured)以減少外界刺激的干擾。此外,病人常因忙於活動而忽略進食與睡眠,導致營養失調與體力衰竭,護理師需提供高熱量、方便攜帶的手指食物(Finger foods)以增加攝取量,並透過限制社交來降低其過度亢奮。臨床思路應優先考慮病人的生理需求與環境安全。
The core nursing goals during a manic episode are to reduce psychological agitation, maintain physiologic needs, and ensure safety. Because the client is in a high-energy, easily distracted, and impulsive state, the environment must be structured to reduce external stimulation. In addition, manic clients often neglect eating and sleep because of their constant activity, leading to nutritional imbalance and exhaustion; the nurse should provide high-calorie, portable finger foods to increase intake and limit social interaction to decrease overstimulation. Clinical reasoning should prioritize physiologic needs and environmental safety.