— 心理社會完整性 · MEDIUM · MCQ —
一位躁鬱症病人處於躁狂期，在走廊來回踱步並快速說話。護理師首要介入措施為何？
A client with bipolar disorder is in a manic phase and is pacing in the hall while speaking rapidly. What is the most appropriate initial nursing intervention?
- AAdminister the prescribed PRN sedative給予處方之備用鎮靜劑
- BConfront the client about their behavior就病人的行為進行對質
- CInstruct the client to sit down and rest指示病人坐下休息
- DProvide a quiet, low-stimulation environment✓ 正解提供安靜、低刺激的環境
— Explanation · 中文詳解 —
躁狂期病人處於高度興奮狀態，感官刺激會加重其躁動。首要護理目標是降低環境刺激，提供一個安靜且結構化的空間，以協助病人降低神經系統的過度喚起，並預防體能耗竭與衝突發生。直接下指令休息或強迫對質可能引發抗拒或攻擊行為。
Providing a quiet, low-stimulation environment is the priority intervention to help reduce the client's heightened arousal and prevent exhaustion during the manic phase. Direct confrontation or commands may escalate agitation, while medication is typically considered after environmental modifications.
✦ 台美臨床差異
台灣病房常設有保護室（隔離室），護理師在美國需更嚴格執行限制最小原則，優先考量非藥物環境干預。