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心理社會完整性 · HARD · SATA

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
Explanation · 中文詳解

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.

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