— 生理適應 · HARD · MCQ —
病人診斷為抗利尿激素分泌不當症候群（SIADH），優先護理評估項目為何？
A client is diagnosed with SIADH. Which nursing assessment is the priority?
- ADaily weight每日體重
- BSkin turgor皮膚彈性
- CSerum sodium level血清鈉濃度
- DNeurological status✓ 正解神經狀態
— Explanation · 中文詳解 —
SIADH（抗利尿激素分泌不當症候群）導致身體過度滯留水分，造成稀釋性低血鈉（Dilutional Hyponatremia）。當血鈉濃度過低，水分會從細胞外液移往細胞內，導致腦細胞水腫（Cerebral edema）。腦水腫會引發顱內壓升高，若未及時處理，會造成意識改變、癲癇甚至腦疝（Herniation）。因此，評估病人的神經功能狀態（Neurological status）是預防生命威脅的優先要務。
SIADH causes water retention and dilutional hyponatremia, which can lead to cerebral edema and increased intracranial pressure. Neurological status is the priority assessment because early signs of hyponatremia, such as confusion or lethargy, indicate brain swelling that can progress to seizures or herniation. While serum sodium levels confirm the diagnosis, neurological changes reflect the immediate physiological threat to the client.