一位加護病房護理師正在評估一名因腦腫瘤剛完成開顱手術的 40 歲男性。在過去一小時內，病患的尿量突增至 850 mL 且極度稀薄，同時血壓下降至 92/58 mmHg。哪項護理行動為首要的臨床優先？
An intensive care nurse evaluates a 40-year-old male post-craniotomy for a massive brain tumor. Over the last hour, the client’s urine output has surged to 850 mL of extremely dilute, pale urine, while his blood pressure has dropped to 92/58 mmHg. Which nursing action takes the utmost priority?
- AIncrease the mechanical ventilator oxygen fraction significantly to combat shock.大幅增加機械通氣的氧氣濃度以對抗休克
- BAdminister a rigorous IV fluid bolus promptly and notify the neurosurgeon.✓ 正解迅速給予大量靜脈輸液並通知神經外科醫師
- CDocument the massive diuresis output as an expected clearing response.記錄大量利尿為預期的清除反應
- DPerform a comprehensive deep neurological pupil assessment exclusively.單獨進行全面的神經學瞳孔評估
本題重複出現以確認神經急症考點的固化 (DI crisis)。開顱後一旦每小時排水超過 200cc 以上並伴隨低比重，就是發生尿崩症 (Diabetes Insipidus)，這是致命休克的開始。優先介入是補水與通報醫師給予藥物 DDAVP。
Post-craniotomy polyuria exceeding 200 mL/hour with dilute urine indicates diabetes insipidus, a life-threatening condition that leads to profound hypovolemic shock. The priority nursing action is to promptly administer an IV fluid bolus to restore circulating volume and notify the neurosurgeon for administration of desmopressin (DDAVP).
DI (尿崩症) 引發的脫水與休克是最高等級神經併發症。