— 健康促進與維護 · MEDIUM · SATA —
護理師向心衰竭病人指導應監測的症狀。下列哪些內容正確？（選所有適合的）
A nurse is teaching a client with newly diagnosed heart failure about symptoms to monitor. Which instructions are correct? (Select all that apply.)
- AWeigh yourself at the same time each day✓ 正解每天同一時間測量體重
- BMonitor for increased shortness of breath with activity✓ 正解監測活動時呼吸困難是否加重
- CReport a weight gain of 3 pounds in one day✓ 正解若一天內體重增加3磅應立即回報
- DDecrease sodium intake to manage fluid retention✓ 正解減少鈉攝取量以控制體液滯留
- EStop taking diuretics if you feel dizzy若感到頭暈應停止服用利尿劑
— Explanation · 中文詳解 —
心衰竭病人的居家監控重點為：每日量體重（監測水腫）、辨識呼吸困難加劇（肺部積水）、限制鈉攝取（減輕負擔）。體重快速增加（如 1 天 3 lbs）需立即聯絡醫療團隊。E 選項錯誤：頭暈可能是低血壓或藥物調整問題，絕不可擅自停用利尿劑，應由醫師評估。
Clients with heart failure should weigh themselves daily at the same time to detect early fluid retention and report sudden gains, such as 3 pounds in one day. They must also monitor for worsening shortness of breath and adhere to a low-sodium diet to manage fluid balance, while never discontinuing prescribed diuretics without medical consultation.
✦ 台美臨床差異
台灣居家護理師針對心衰竭個案的追蹤頻率，常受限於人力與健保結構，故病人自主監測能力至關重要。