一位診斷為僵直型思覺失調症的病人入院。哪項護理干預是首要任務?
A client is admitted to the psychiatric unit with a diagnosis of catatonic schizophrenia. Which nursing intervention is a priority?
- AEngaging the client in group activities to improve social skills引導病人參與團體活動以改善社交技巧
- BTeaching the client about the importance of medication compliance教導病人服藥依從性的重要性
- CAdministering antipsychotic medications as scheduled按時給予抗精神病藥物
- DProviding frequent fluid intake and monitoring nutritional status✓ 正解頻繁提供液體攝取並監測營養狀況
僵直型思覺失調症(Catatonia)的病人可能長時間維持固定姿勢、不語、不食、不動。在這種狀態下,病人的生理安全面臨極大威脅,包括脫水、營養不良、褥瘡以及深層靜脈栓塞(DVT)。因此,首要的護理處置是維持生理機能,確保足夠的液體與營養攝取。雖然精神科藥物(選項 C)對治療疾病本身至關重要,但在病人無法進食水的情況下,生理衰竭是立即的危險。社交活動或衛教對於目前處於僵直狀態的病人來說完全無法執行。
For clients with catatonic schizophrenia, physiological safety takes priority as they may be unable to eat or drink, risking dehydration and malnutrition. While antipsychotic medication is essential for treatment, immediate nursing interventions must focus on maintaining hydration and nutritional status to prevent life-threatening physical deterioration.
美國 NCLEX 考題常將精神疾病中的『生理風險』作為陷阱,考驗學生是否能識別精神症狀背後的致命生理問題;台灣臨床照護有時會過度依賴靜脈輸液,較少細緻地討論僵直病人的皮膚與循環護理細節。