— 生理適應 · MEDIUM · MCQ —
一位閉鎖性頭部外傷病人併發尿崩症(Diabetes Insipidus),下列哪項護理觀察是預期的?
A client with a closed head injury has developed diabetes insipidus. Which nursing observation is expected?
- AExcessive dilute urine output✓ 正解大量稀釋尿液排出
- BSpecific gravity of 1.035尿液比重 1.035
- CDecreased serum sodium血清鈉降低
- DPeripheral edema周邊水腫
— Explanation · 中文詳解 —
尿崩症(Diabetes Insipidus, DI)是因為大腦下視丘受損導致抗利尿激素(Antidiuretic Hormone, ADH)分泌不足,或腎臟對 ADH 無反應。ADH 的缺乏使腎小管遠端與集尿管無法重吸收水分,導致大量水分隨尿液排出。臨床上,護理師應預期病人出現極度稀釋的尿液,伴隨尿量大幅增加與口渴感。此病人的核心風險在於嚴重脫水與高血鈉,護理重點為監測體液平衡、電解質及尿液比重。
Diabetes insipidus results from a deficiency of antidiuretic hormone (ADH) or renal resistance to it, leading to the inability of the kidneys to concentrate urine. Consequently, the nurse should expect excessive output of large volumes of dilute urine, which places the client at risk for severe dehydration and hypernatremia.