— 心理社會完整性 · HARD · MCQ —
一位厭食症個案開始進行營養復健。下列哪項護理觀察為最高優先？
A client diagnosed with anorexia nervosa is beginning nutritional rehabilitation. Which nursing observation is the highest priority?
- AWatching for signs of refeeding syndrome✓ 正解觀察復甦綜合症的跡象
- BAssessing the client's body image perception評估病人的身體意象認知
- CStrict monitoring of calorie intake嚴格監測熱量攝取量
- DEnsuring the client participates in group therapy確保病人參與團體治療
— Explanation · 中文詳解 —
厭食症個案在恢復進食過程中，最致命的生理風險是「再餵食症候群（Refeeding Syndrome）」。當長期營養不良的身體重新攝取熱量時，會引發胰島素快速分泌，導致細胞外磷、鉀、鎂等離子大量轉移至細胞內，造成嚴重的電解質失衡，進而引發心律不整甚至猝死。護理師需在復健初期密切監測實驗室數據與生命徵象。
Refeeding syndrome is a life-threatening complication characterized by severe electrolyte shifts, particularly hypophosphatemia, when nutrition is reintroduced to a malnourished client. This rapid insulin release drives phosphorus, potassium, and magnesium into cells, potentially causing cardiac arrhythmias and death, making physiological monitoring the highest priority.