— 生理適應 · MEDIUM · SATA —
護理師為新診斷心衰竭的病人制定衛教計畫，應包含哪些內容？（選所有適合的）
A nurse is caring for a client with a new diagnosis of heart failure. Which interventions should the nurse include in the teaching plan? (Select all that apply.)
- ADaily weight monitoring✓ 正解每日體重監測
- BLow-sodium diet adherence✓ 正解低鈉飲食遵從
- CIncrease fluid intake to 3L daily每日增加3公升液體攝取
- DReport weight gain of >3 lbs in 2 days✓ 正解體重於2天內增加超過3英磅時予以回報
- EMonitor for dyspnea on exertion✓ 正解監測活動後呼吸困難
— Explanation · 中文詳解 —
心衰竭（Heart Failure）的衛教核心在於預防液體過負荷與早期發現失代償跡象。護理目標為維持心輸出量、減輕心臟負荷及預防肺水腫。體重監測是評估體液滯留最敏感的指標，限鈉可減少體液滯留，而監測呼吸困難則是評估心肺代償功能的關鍵。鼓勵液體攝取會增加心臟前負荷（preload），對於心衰竭病人是禁忌。
Nursing teaching for heart failure should emphasize daily weight monitoring and low-sodium diets to manage fluid retention, as rapid weight gain and dyspnea indicate worsening condition. Increasing fluid intake is contraindicated because it exacerbates volume overload and increases cardiac preload.