— 心理社會完整性 · MEDIUM · SATA —
對於出現譫妄症狀的病人，下列哪些護理措施是適當的？（選所有適合的）
Which of the following interventions are appropriate for a client exhibiting symptoms of delirium? (Select all that apply.)
- AMaintain a quiet, well-lit environment✓ 正解維持安靜且照明良好的環境
- BPlace a clock and calendar in the room✓ 正解在房間內放置時鐘和日曆
- CEncourage the client to make complex decisions鼓勵病人做出複雜的決定
- DConsistently identify yourself and current time✓ 正解持續自我介紹並告知當前時間
- ELimit the number of staff members interacting with the client✓ 正解限制與病人互動的醫護人員數量
— Explanation · 中文詳解 —
譫妄（Delirium）是一種急性、可逆的意識狀態改變，臨床護理核心在於提供「定向感維持」與「減少環境刺激」。病人常因認知功能障礙而感到混亂與恐懼，因此護理措施應聚焦於重建現實感（Reality orientation），並避免病人因過度感官刺激而產生躁動。對於譫妄病人，過於複雜的決策會增加認知負荷，導致挫折感，因此需簡化環境與互動。
Delirium management focuses on maintaining orientation and minimizing environmental stimuli to reduce sensory overload and anxiety. Interventions such as providing clocks and calendars, consistent identification by staff, and limiting the number of caregivers help ground the client in reality. Conversely, encouraging complex decisions increases cognitive load and should be avoided.