— 生理適應 · HARD · SATA —
護理師照護一位抗利尿激素分泌異常症候群（SIADH）病人。下列哪些護理措施應納入照護計畫？（選所有適合的）
A nurse is caring for a client with SIADH. Which nursing interventions should the nurse include in the plan of care? (Select all that apply.)
- ARestrict fluid intake✓ 正解限制水分攝取
- BAdminister hypertonic saline as ordered✓ 正解依處方給予高張鹽水
- CMonitor for symptoms of fluid overload✓ 正解監測液體過載症狀
- DEncourage high sodium intake鼓勵高鈉飲食
- EMaintain head of bed at 30 degrees保持床頭抬高 30 度
— Explanation · 中文詳解 —
SIADH 特徵是水滯留及稀釋性低血鈉。治療重點為限水（A）、給予高張鹽水（B）以糾正鈉值，並監測水過量（C）。D 選項錯誤，病人本身體液過多，不應額外鼓勵過度攝取鈉，重點在於限制水分攝取。E 非針對 SIADH 的主要處置。
SIADH is characterized by water retention and dilutional hyponatremia. Treatment focuses on fluid restriction (A), administering hypertonic saline (B) to correct sodium, and monitoring for fluid overload (C). Option D is incorrect; the client already has fluid excess and should not be encouraged to take in extra sodium; the focus is on limiting fluid intake. E is not a primary SIADH intervention.
✦ 台美臨床差異
美國護理師在監測嚴重低血鈉病人的神經症狀較為積極，台灣臨床則更側重於嚴格執行精確的輸出入量紀錄。