— 降低風險 · MEDIUM · MCQ —
護理師照護心衰竭病人。下列哪項指導對預防急性惡化至關重要？
A nurse is caring for a client with a history of heart failure. Which instruction is crucial to teach the client to prevent acute exacerbations?
- AIncrease sodium intake for electrolyte balance增加鈉攝取以維持電解質平衡
- BWeigh yourself daily✓ 正解每日測量體重
- CAvoid all forms of physical activity避免所有形式的體力活動
- DLimit protein intake限制蛋白質攝取
— Explanation · 中文詳解 —
每日固定時間量體重是居家心衰竭自我監測的最重要指標。若體重在 24 小時內增加超過 2 lbs 或一週增加 >5 lbs，代表有水分滯留，應立即回診以免失代償。其他選項如增加鈉攝取、過度限蛋白或完全臥床均不符合指引。
Daily weight monitoring is the most sensitive indicator of fluid retention in clients with heart failure. An increase of more than 2 pounds in 24 hours or 5 pounds in a week suggests worsening condition requiring medical attention.
✦ 台美臨床差異
美台皆強調每日體重的重要性，美國護理師常會協助病人建立記錄表。