— 基本照護與舒適 · HARD · SATA —
護理師為視力受損病人制定計劃。哪些措施能促進安全與獨立？（選所有適合的）
A nurse is planning care for a client with a visual impairment. Which interventions promote safety and independence? (Select all that apply.)
- ADescribe the location of food on the plate using a clock face✓ 正解使用時鐘面描述盤中食物的位置
- BRearrange the furniture regularly to keep the client alert定期重新擺放傢俱以保持病人警覺
- CKeep the door either completely open or completely closed✓ 正解將門保持完全打開或完全關閉
- DIdentify yourself when entering the room✓ 正解進入房間時自我介紹
- ESpeak in a very loud voice so the client can hear you用非常大的聲音說話以便病人聽見
— Explanation · 中文詳解 —
為視力受損病人制定照護計畫，其核心目標是最大程度地促進他們的安全性與獨立性。這不僅涉及物理環境的調整，更包括護理師在溝通和互動上的細膩考量。由於視力受損病人仰賴其他感官來感知周遭環境，因此提供一致、可預測的環境，並透過清晰、尊重的口語溝通來引導，是確保他們能安全、自信地參與日常活動的關鍵。護理師的介入應旨在減少潛在的危險，同時賦予病人自主權，讓他們能夠在醫療環境中感到安心與被尊重。這符合以病人為中心的照護理念，強調個體化的支持。
Clients with suspected pulmonary embolism require monitoring for sudden dyspnea, pleuritic chest pain, tachycardia, and hemoptysis due to impaired gas exchange and potential pulmonary infarction. Bradypnea is not expected; instead, tachypnea occurs as a compensatory mechanism for hypoxia and decreased cardiac output.