— 生理適應 · MEDIUM · SATA —
護理師照護一位尿崩症病人，護理計畫應包含哪些措施？（選所有適合的）
A nurse is caring for a client with diabetes insipidus. Which nursing interventions should be included in the plan of care? (Select all that apply.)
- AMonitor daily weights✓ 正解監測每日體重
- BRestrict fluid intake限制液體攝取
- CMonitor urine specific gravity✓ 正解監測尿液比重
- DAssess skin turgor✓ 正解評估皮膚彈性
- EAdminister desmopressin as prescribed✓ 正解依醫囑給予去氨加壓素
— Explanation · 中文詳解 —
尿崩症病人因 ADH 不足導致水分大量流失。護理重點包括監測每日體重（評估脫水狀況）、尿比重（監測濃縮能力）、皮膚彈性。藥物治療給予去氨加壓素 (DDAVP) 以替代 ADH 功能。B 選項錯誤：限制水分會造成嚴重的脫水與高血鈉，病人需要補水。
Nursing care for diabetes insipidus includes monitoring daily weights and urine specific gravity to accurately assess fluid balance and renal concentrating ability. Skin turgor should be assessed to detect signs of dehydration resulting from excessive polyuria. Desmopressin is administered to replace deficient antidiuretic hormone, whereas fluid restriction is contraindicated as it would exacerbate dehydration and hypernatremia.
✦ 台美臨床差異
美台臨床皆視尿崩症為內分泌急重症，護理重點均在於嚴格的 I/O 監測及補水策略。