— 生理適應 · MEDIUM · MCQ —
一位肝硬化病人出現意識混亂與手部拍擊樣震顫（flapping tremor）。護理師應優先執行哪項措施？
A client with cirrhosis is experiencing confusion and a flapping tremor. Which nursing action is the highest priority?
- AMaintain a high-protein diet for tissue repair維持高蛋白飲食以促進組織修復
- BEncourage the client to ambulate to prevent DVT鼓勵病人下床活動以預防深部靜脈栓塞
- CMonitor the client for signs of hypotension監測病人是否有低血壓跡象
- DAdminister lactulose as prescribed✓ 正解依處方給予乳果糖
— Explanation · 中文詳解 —
肝硬化病人若出現意識混亂與手部拍擊樣震顫（Asterixis），這是肝性腦病變（Hepatic encephalopathy）的典型表現，主因是肝臟無法代謝氨（Ammonia），導致血氨升高影響大腦功能。乳果糖（Lactulose）是治療首選，其機轉是酸化腸道環境，促使氨轉變為離子狀態並隨糞便排出，降低血氨濃度。
Administering lactulose is the highest priority to treat hepatic encephalopathy, as it reduces serum ammonia levels by acidifying the gut and promoting excretion. High-protein diets can worsen symptoms by increasing ammonia production, while other interventions do not address the immediate neurological threat.