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生理適應 · EASY · MCQ

一位有中風病史的病人因吞嚥困難入院。為預防吸入性肺炎,哪項護理措施最重要?

A client with a history of stroke is admitted with dysphagia. Which nursing intervention is most important to prevent aspiration?

  • AEncourage the client to drink fluids quickly
    鼓勵客戶快速飲水
  • BOffer a diet of thin liquids
    提供稀薄液體飲食
  • CPosition the client in a semi-Fowler's or high-Fowler's position during and after meals✓ 正解
    在進餐期間及餐後將客戶置於半坐臥位或高坐臥位
  • DAllow the client to feed themselves independently
    允許客戶獨立自行進食
Explanation · 中文詳解

中風病人常伴有吞嚥功能障礙(Dysphagia),預防吸入性肺炎(Aspiration Pneumonia)是護理照護的重中之重。利用重力輔助是減少誤吸最有效且非侵入性的方法。將床頭抬高至少 30 至 45 度(半坐臥或高坐姿),能確保食物順利通過食道進入胃部,同時防止胃內容物逆流。護理師應在進食前評估病人的吞嚥反射,並在進食過程中與進食後一段時間內保持此姿勢,以確保安全。

Patients who have had a stroke often have dysphagia, and preventing aspiration pneumonia is a top priority of nursing care. Using gravity as an aid is the most effective and non-invasive method of reducing aspiration. Elevating the head of the bed to at least 30 to 45 degrees (semi-Fowler's or high Fowler's position) ensures that food passes smoothly through the esophagus into the stomach and prevents reflux of gastric contents. The nurse should assess the patient's swallowing reflex before feeding and maintain this position during feeding and for a period afterward to ensure safety.

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