— 生理適應 · EASY · MCQ —
護理師正在審閱一位心臟衰竭病人的照護計畫。哪個護理診斷最適用於這位病人？
A nurse is reviewing the care plan for a client with heart failure. Which nursing diagnosis is most appropriate for this client?
- AActivity intolerance related to imbalance between oxygen supply and demand✓ 正解活動耐力不足，與氧氣供需失衡有關
- BImbalanced nutrition: Less than body requirements營養失調：低於身體需求
- CDeficient knowledge regarding disease management缺乏疾病管理的知識
- DRisk for infection感染風險
— Explanation · 中文詳解 —
心臟衰竭導致心臟泵血功能下降，使得身體組織無法獲得足夠的氧氣供應，進而影響活動能力，造成活動不耐。因此，「活動不耐」是心臟衰竭病人最常見且核心的護理診斷之一。其他選項可能存在，但 B 是最直接反映心臟功能障礙的生理適應不良。
Heart failure reduces cardiac output, leading to an imbalance between oxygen supply and demand in body tissues, which directly causes activity intolerance. This nursing diagnosis is the most appropriate as it addresses the primary physiological consequence of the disease process, whereas other options are either secondary issues or general risks.
✦ 台美臨床差異
美國護理師在制定照護計畫時，會優先考慮病人最核心的生理適應問題；台灣的護理診斷應用也相似，但可能因病人情況複雜度，多個診斷會同時考量。