— 生理適應 · HARD · MCQ —
病人診斷為抗利尿激素分泌失調症候群 (SIADH)，護理師應準備執行下列哪項措施？
A client is admitted with a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should prepare to implement which of the following interventions?
- AAdminister isotonic saline bolus給予等張鹽水推注
- BIncrease oral fluid intake增加口服液體攝取
- CRestrict total daily fluid intake✓ 正解限制每日總液體攝取量
- DEncourage a high-sodium diet鼓勵高鈉飲食
— Explanation · 中文詳解 —
SIADH 是因為身體過度分泌 ADH，導致水分再吸收增加，造成稀釋性低血鈉。護理的核心目標是糾正水分過多，故嚴格限制每日水分攝取量是首要醫療處置，以達到負平衡。給予大量水分會加劇病況，給予 isotonic saline 並非主要糾正手段。
SIADH causes excessive water retention and dilutional hyponatremia due to inappropriate ADH secretion. The primary nursing intervention is strict fluid restriction to create a negative water balance and correct the electrolyte imbalance.
✦ 台美臨床差異
美方對於嚴格限水（如 800-1000mL/day）執行極為嚴格，包含所有靜脈輸注量計算；台灣臨床護理有時會忽略計入沖管量。