— 心理社會完整性 · MEDIUM · MCQ —
護理師正在為一位有創傷史的病人制定照護計畫。病人表現出過度警覺和睡眠困難，最恰當的護理介入措施是什麼？
A nurse is developing a care plan for a client with a history of trauma. The client exhibits hypervigilance and difficulty sleeping. Which nursing intervention is most appropriate?
- AAdvise the client to avoid discussing the trauma.建議病人避免討論創傷經歷。
- BIncrease sensory stimuli to help the client relax.增加感官刺激以幫助病人放鬆。
- CProvide a structured and predictable environment.✓ 正解提供結構化且可預測的環境。
- DEncourage the client to suppress traumatic memories.鼓勵病人壓抑創傷記憶。
— Explanation · 中文詳解 —
對於有創傷史的病人，核心照護目標是建立安全感 (Sense of Safety)。過度警覺 (Hypervigilance) 是創傷後壓力症候群 (PTSD) 的常見反應，源於對環境威脅的持續評估。結構化與可預測的環境能大幅降低病人的認知負荷，減少因未知變數引發的焦慮，進而改善睡眠品質。反之，強制壓抑記憶或過度刺激會加重病人的心理防衛機制，導致症狀惡化。
For clients with a history of trauma exhibiting hypervigilance, establishing a sense of safety is the primary goal. Providing a structured and predictable environment reduces cognitive load and anxiety associated with unknown variables, thereby helping to alleviate hypervigilance and improve sleep quality.