— 基本照護與舒適 · MEDIUM · MCQ —
病人的體溫為 102.2°F (39°C)。哪項護理行動是適當的？
A client has a temperature of 102.2°F (39°C). Which nursing action is appropriate?
- AWithhold fluids to prevent vomiting限制液體攝取以防止嘔吐
- BAdminister an antipyretic as ordered✓ 正解依醫囑給予退燒藥
- CCover the client with multiple heavy blankets用多層厚毯子覆蓋病人
- DIncrease the room temperature to avoid shivering提高室溫以避免寒顫
— Explanation · 中文詳解 —
發燒時，體溫調節中樞（下視丘）的設定點上升。適當的護理措施應協助病人散熱並維持舒適。給予退燒藥（Antipyretic）能直接作用於下視丘，使設定點恢復正常。過度保暖或環境高溫會阻礙熱量蒸發與輻射散失，導致核心體溫進一步升高，甚至誘發熱衰竭。此外，發燒會增加代謝速率與水分流失，應鼓勵攝取水分，而非限制。
Administering an antipyretic as ordered is appropriate because it acts on the hypothalamus to reset the elevated thermoregulatory set point back to normal. Interventions such as covering the client with heavy blankets or increasing room temperature should be avoided as they trap heat and impede the body's ability to dissipate warmth.