— 生理適應 · MEDIUM · SATA —
護理師向一位心臟衰竭病人提供出院指導。應包含哪項關於管理體液的指導？（選所有適合的）
A nurse is providing discharge instructions to a client with heart failure. Which instruction should be included to manage fluid volume? (Select all that apply.)
- AWeigh yourself daily at the same time each morning✓ 正解每天清晨同一時間測量體重
- BLimit fluid intake to 1.5 liters per day✓ 正解將水分攝取量限制在每天 1.5 公升
- CDiscontinue diuretics if you feel better若感覺好轉就停止服用利尿劑
- DReport a weight gain of more than 2 lbs in 24 hours✓ 正解若 24 小時內體重增加超過 2 磅則回報
- EConsume a high-sodium diet to maintain energy levels攝取高鈉飲食以維持體力
— Explanation · 中文詳解 —
心衰竭病人需嚴格管理體液。每日量體重是監測水腫早期指標；限制水分攝取（通常 1.5-2L/day）可減少體液負荷；體重 24 小時增加 >2 lbs 是失代償警訊，需回報。高鈉飲食和自行停利尿劑會加劇病情。
Clients with heart failure require strict fluid management. Daily weight monitoring is an early indicator of edema; restricting fluid intake (commonly 1.5-2 L per day) reduces fluid overload; and a weight gain of more than 2 lbs within 24 hours is a warning sign of decompensation that must be reported. A high-sodium diet and self-discontinuation of diuretics worsen the disease.
✦ 台美臨床差異
美國心臟衰竭照護計劃常包含社工和營養師，提供全方位的支持；台灣病人需加強居家自我照護能力，護理師衛教是關鍵。