護理師照護一位躁期發作的個案,下列哪些處置應列入護理計畫?(選所有適合的)
A nurse is caring for a client experiencing a manic episode. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AProvide high-protein, high-calorie finger foods✓ 正解提供高蛋白、高熱量的手指食物
- BMaintain a quiet, low-stimulation environment✓ 正解維持安靜、低刺激的環境
- CEncourage the client to join group therapy sessions鼓勵病人參加團體治療課程
- DMonitor for signs of dehydration and nutritional deficit✓ 正解監測脫水和營養不良的跡象
- ELimit physical activity to decrease energy expenditure限制身體活動以降低能量消耗
躁期(Manic episode)個案常處於極度興奮、活動量大且睡眠需求減少的狀態。護理計畫重點在於維持生理平衡與安全。由於病人常忘記進食,提供方便攜帶的高熱量手拿食物(Finger foods)可確保營養攝取。維持安靜、低刺激的環境有助於減少病人的過度興奮。監測脫水與營養狀況是預防生理衰竭的必要措施。
Clients in a manic episode are often extremely energetic, highly active, and have a reduced need for sleep. The nursing plan focuses on maintaining physiologic balance and safety. Because the client frequently forgets to eat, providing portable, high-calorie finger foods helps ensure nutritional intake. Maintaining a quiet, low-stimulation environment helps reduce hyperarousal. Monitoring for dehydration and nutritional deficits is essential to prevent physical exhaustion.