— 心理社會完整性 · HARD · SATA —
護理師在忙碌的加護病房中，應觀察到個案出現感覺超載的哪些徵象？（選所有適合的）
Which assessment findings should the nurse expect in a client experiencing sensory overload in a busy ICU? (Select all that apply.)
- AIncreased agitation and restlessness✓ 正解躁動與不安增加
- BHypersensitivity to sounds and light✓ 正解對聲音和光線過敏
- CDecreased heart rate and respiration心率和呼吸減慢
- DDisorientation and confusion✓ 正解定向感障礙與混淆
- EWithdrawal from social interaction✓ 正解社交互動退縮
— Explanation · 中文詳解 —
加護病房（ICU）內持續的監測儀器聲、強光與頻繁的護理活動會導致病人感覺超載（Sensory Overload）。當神經系統無法處理過多刺激時，會引發交感神經系統過度興奮，導致焦慮、躁動、對環境刺激敏感、認知功能混亂及社交退縮，這是病人自我保護的心理機制。護理師需透過環境調整（如減光、噪音管理）來降低病人的壓力。
Sensory overload in the ICU often manifests as increased agitation, restlessness, hypersensitivity to stimuli, disorientation, and withdrawal from social interaction. These responses occur because the nervous system becomes overwhelmed by excessive environmental input, leading to sympathetic stimulation and impaired cognitive processing. Vital signs typically increase rather than decrease due to this heightened state of arousal.