護理師正在照顧一位正處於急性躁症發作的雙相情緒障礙症(第一型)病人。該病人目前在走廊徘徊、對其他病人大聲吼叫,且已 48 小時未入睡。下列哪項護理措施為優先?
A nurse is caring for a client with Bipolar I Disorder who is experiencing acute mania. The client is pacing the hallway, shouting at other clients, and has not slept for 48 hours. Which nursing intervention is the priority?
- AEscort the client to a quiet, low-stimulus area✓ 正解引導病患至安靜、低刺激的區域
- BEncourage the client to join a group therapy session鼓勵病患參加團體治療課程
- CProvide a high-calorie finger food and a bottle of water提供高熱量手指食物和一瓶水
- DAdminister a PRN dose of lorazepam as prescribed依醫囑給予處方劑量的勞拉西泮 (lorazepam) 作為必要時 (PRN) 用藥
對於急性躁症病人,護理的首要原則是維持環境的安全並降低過度的外在刺激(Milieu management)。躁症發作時,病人對環境刺激非常敏感,走廊徘徊與對人吼叫顯示其情緒已受過度激發,將其引導至安靜、低刺激的區域(Option A)能有效降低其激動程度,預防潛在的攻擊行為,並為後續的營養補充與休息提供基礎。雖然鎮靜藥物(Option D)可能必要,但在評估環境因素前應先嘗試非藥物干預,且藥物需時間作用;高熱量食物(Option C)對體力耗竭的病人很重要,但若病人處於激動衝突狀態,其安全威脅高於即時營養。團體治療(Option B)對躁症病人是禁忌,因為過多的人際互動會使其症狀惡化。
Reducing environmental stimuli is the priority intervention for a manic client to lower arousal levels and prevent aggression. Moving the client to a quiet area addresses immediate safety needs before administering medication or providing nutrition.
在美國,精神科病房強調『低刺激環境(Low-stimulus environment)』的標準化執行,甚至有專門的小房間;台灣臨床實務中,護理師除了隔離外,也常較早介入藥物鎮靜(Chemical restraint),且較依賴家屬或看護的安撫作用。