— 生理適應 · HARD · MCQ —
個案血鈉濃度為 125 mEq/L。下列哪項護理行動最關鍵？
A client has a serum sodium level of 125 mEq/L. Which nursing action is most critical?
- AInitiate seizure precautions✓ 正解實施防癲癇 precautions
- BAdminister furosemide給予 furosemide
- CEncourage free water intake鼓勵攝取自由水
- DIncrease dietary salt intake增加飲食鹽分攝取
— Explanation · 中文詳解 —
血鈉濃度 125 mEq/L 屬於嚴重低血鈉（Hyponatremia）。當血鈉過低時，血液滲透壓下降，水分會從血管移動至細胞內，導致腦細胞水腫（Cerebral edema）。腦細胞水腫會引發神經系統症狀，如意識混亂、嗜睡，嚴重者會導致癲癇發作（Seizures）。因此，預防癲癇發作是保護病人生命安全的核心護理行動。
A serum sodium of 125 mEq/L represents severe hyponatremia. When serum sodium is low, plasma osmolality falls, and water shifts from the vasculature into the cells, leading to cerebral edema. Cerebral edema can produce neurologic symptoms such as confusion and lethargy, and in severe cases can precipitate seizures. Therefore, preventing seizures is the core nursing action to protect the patient's life and safety.