— 心理社會完整性 · HARD · MCQ —
護理師照顧一位體重僅達理想體重 65% 的厭食症病人。應優先實施哪項措施？
A nurse is caring for a client with anorexia nervosa who is at 65% of her ideal body weight. Which intervention should the nurse implement first?
- AEncourage the client to express feelings about body image.鼓勵個案表達對身體形象的感受
- BSet up a contract for incremental weight gain.簽訂漸進式體重增加的合約
- CSupervise the client for one hour after each meal.在每餐後監督個案一小時
- DMonitor the client's vital signs and electrolyte levels.✓ 正解監測個案的生命徵象和電解質水平
— Explanation · 中文詳解 —
雖然厭食症是心理疾病，但當體重過低（<75% 理想體重）時，生理穩定性（如心律不整、電解質不平衡）是首要威脅。在處理心理議題或行為限制（C）之前，必須先監測並穩定其生理狀態。B 和 A 是後續治療過程，但在急性期「生命安全」優先。
Physical stability is the priority in severe malnutrition to prevent life-threatening complications such as cardiac arrest. Although psychosocial interventions are important, the immediate focus must be on monitoring vital signs and electrolyte levels to ensure physiological safety before addressing behavioral or emotional issues.
✦ 台美臨床差異
美國對於厭食症的強制住院標準（如心律、電解質）有非常具體的指引；台灣則較依賴個別醫師的判斷。