— 生理適應 · MEDIUM · MCQ —
一位腹水伴隨肝性腦病變的病人。哪項是優先的護理目標？
A nurse is caring for a client with ascites and hepatic encephalopathy. What is the priority nursing goal?
- AMonitor for weight loss監測體重減輕
- BReduce ammonia levels✓ 正解降低氨濃度
- CIncrease sodium intake to prevent hyponatremia增加鈉攝取量以預防低血鈉
- DIncrease protein intake to build strength增加蛋白質攝取量以增強體力
— Explanation · 中文詳解 —
肝性腦病變（Hepatic encephalopathy）是由於肝臟功能衰竭，無法將氨（Ammonia）轉化為尿素，導致血氨升高並損害腦部功能。降低血氨是治療的核心目標。通常使用 Lactulose，其機轉是酸化腸道，使氨轉變為銨離子（Ammonium）並促進排出。限制蛋白質攝取可減少氨的生成，但需維持基本營養。監測精神狀態與血氨濃度是護理的優先目標。
The priority goal is to reduce ammonia levels, as elevated ammonia contributes to hepatic encephalopathy and neurological decline. Interventions such as administering lactulose help acidify the colon to convert ammonia into ammonium for excretion, thereby protecting brain function.