一位老年病人出現譫妄症狀，護理照護計畫應包含哪些措施？（選所有適合的）
A nurse is caring for an older adult experiencing symptoms of delirium. Which intervention should the nurse include in the plan of care? (Select all that apply.)
- AProvide a calendar and clock in the room✓ 正解在病房內提供日曆和時鐘
- BMaintain a consistent daily routine✓ 正解維持一致的每日作息
- CFrequently reorient the client to place and time✓ 正解經常協助病人重新定向至當前地點與時間
- DCluster all nursing care to ensure long periods of uninterrupted sleep集中安排所有護理活動，以確保長時間不受打擾的睡眠
- EEncourage family members to bring familiar personal items✓ 正解鼓勵家屬攜帶熟悉的個人物品
譫妄個案常見定向感障礙與混亂，照護重點在於「環境定向感」與「規律性」。時鐘與日曆提供視覺線索，規律的作息能降低焦慮。家族物品能提供熟悉感，減少對陌生環境的恐懼。選項 D 錯誤，雖須減少夜間干擾，但護理工作應適度分散，避免過度疲勞影響身心。
Clients with delirium commonly experience disorientation and confusion; nursing care emphasizes environmental orientation and routine. A calendar and clock provide visual cues, and a predictable schedule reduces anxiety. Familiar personal items from family members offer a sense of familiarity and reduce fear of an unfamiliar environment. Option D is incorrect: although nighttime interruptions should be minimized, nursing care should be reasonably spaced rather than entirely clustered, to avoid exhausting the client physically and mentally.
美台皆強調環境控制，但在台灣因人力限制，家屬陪病制度使得家人參與照護（選項E）更為普遍。