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生理適應 · MEDIUM · MCQ

護理師評估一位近期中風並出現單側忽略的病人。哪項護理措施最適合?

A nurse is assessing a client who recently had a stroke and is experiencing unilateral neglect. Which nursing intervention is most appropriate?

  • ARemind the client to scan the environment and pay attention to the affected side✓ 正解
    提醒病人掃描環境並注意患側
  • BFeed the client entirely on the unaffected side
    完全在健側餵食病人
  • CPlace objects on the unaffected side of the client
    將物品放置在病人健側
  • DEncourage the client to ignore the affected side
    鼓勵病人忽略患側
Explanation · 中文詳解

單側忽略(Unilateral Neglect)常見於右大腦半球受損的中風病人,病人會對患側的刺激失去感知。護理介入的重點在於「再教育」大腦,透過強迫病人主動掃描(Scanning)患側環境,增加對該側的覺察。護理師應安排病房設施,將物品放在患側,鼓勵病人轉頭並伸手去拿,從復健的角度協助病人恢復對空間的感知。

Unilateral neglect is common in stroke patients with right hemisphere damage; the client loses awareness of stimuli on the affected side. The focus of nursing intervention is on 're-educating' the brain by having the client actively scan the affected side of the environment to increase awareness of that side. The nurse should arrange the room so that items are placed on the affected side, encouraging the client to turn the head and reach toward that side to help them regain spatial awareness through rehabilitation.

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