— 心理社會完整性 · MEDIUM · MCQ —
護理師照顧一位發生譫妄的高齡病人，哪項護理介入最適當？
A nurse is caring for an older adult client experiencing delirium. Which nursing intervention is most appropriate?
- AProvide a structured environment with frequent reorientation✓ 正解提供結構化的環境並經常進行定向引導
- BLimit visitors to prevent overstimulation限制探視人數以防止過度刺激
- CAdminister PRN sedatives to manage agitation給予備用（PRN）鎮靜劑以管理激躁行為
- DKeep the room lights dim to facilitate sleep保持房間燈光昏暗以促進睡眠
— Explanation · 中文詳解 —
譫妄病人需要的是提供定向感與環境結構。透過頻繁的定向感連結（Reorientation）與維持規律作息，可減少混亂。光線昏暗（D）可能導致視幻覺加劇；限制訪客（B）若缺乏支持可能會增加孤立感；鎮靜劑（C）應謹慎使用，以免惡化認知功能。
Frequent reorientation helps the client maintain contact with reality and reduces confusion associated with delirium. Providing a structured environment supports this process, whereas dim lighting or unnecessary sedation can worsen symptoms.
✦ 台美臨床差異
美國推行預防譫妄的 HELP 計畫（Hospital Elder Life Program）；台灣臨床常以約束作為管理譫妄激躁的首選，需反思。