— 照護管理 · HARD · SATA —
護理師照顧的病人突然出現混亂與躁動，應優先採取哪些措施？（選所有適合的）
A nurse is caring for a client who suddenly becomes confused and restless. Which interventions should the nurse prioritize? (Select all that apply.)
- AAssess oxygen saturation levels✓ 正解評估血氧飽和度
- BCheck blood glucose levels✓ 正解檢查血糖值
- CAdminister a PRN sedative給予處方備用鎮靜劑
- DReorient the patient to time and place協助病人重新定向時間與地點
- EMonitor blood pressure and heart rate✓ 正解監測血壓與心率
— Explanation · 中文詳解 —
突然出現的意識混亂與躁動（Delirium）通常是身體生理恆定失衡的警訊。護理師應運用 ABCs 原則（Airway, Breathing, Circulation）進行評估，排除低血氧（影響中樞神經）、低血糖（神經元能量供應不足）及血液動力學不穩定（休克導致腦灌流不足），這些皆是致命且可逆的原因。
Sudden confusion and restlessness often indicate acute physiological instability, so the nurse must prioritize assessing oxygen saturation, blood glucose, and vital signs. These assessments help identify reversible causes such as hypoxemia, hypoglycemia, or hemodynamic instability, whereas sedatives may mask symptoms and worsen the condition.