護理師照顧一位處於躁期(manic episode)的雙相情感障礙病人,哪些介入是適當的?(選所有適合的)
A nurse is caring for a client with bipolar disorder experiencing a manic episode. Which nursing actions are appropriate? (Select all that apply.)
- AProvide finger foods that are high in calories✓ 正解提供高熱量的手指食物
- BSet firm, consistent limits on inappropriate behaviors✓ 正解對不當行為設定堅定且一致的界限
- CEncourage the client to participate in group sports to burn energy鼓勵病人參與團體運動以消耗體力
- DMinimize environmental stimuli✓ 正解最小化環境刺激
- EMaintain a low-stimulation, quiet environment✓ 正解維持低刺激、安靜的環境
躁期(Manic episode)病患表現為活動量過大、易分心且忽略基本生理需求(如進食、睡眠)。護理介入應以「安全」與「減少過度刺激」為原則。提供易攜帶的高熱量食物(Finger foods)能確保病人在無法靜坐時仍能獲得營養;設定明確界線能保護病患與他人安全;降低環境刺激能協助病患降低亢奮程度。
During a manic episode, clients have increased energy and difficulty sitting still, so providing high-calorie finger foods ensures adequate nutrition without requiring them to stop moving. Setting firm, consistent limits provides necessary structure and safety for both the client and others. Minimizing environmental stimuli and maintaining a quiet, low-stimulation environment helps reduce overstimulation, which can exacerbate racing thoughts and agitation.