— 生理適應 · HARD · MCQ —
一位經診斷為抗利尿激素分泌失調症（SIADH）的病患，下列哪項護理措施最為關鍵？
A client diagnosed with SIADH (Syndrome of Inappropriate Antidiuretic Hormone) is receiving care. Which of the following nursing interventions is most critical?
- AInitiate seizure precautions✓ 正解實施防癲癇 precautions
- BIncrease fluid intake to 3 liters per day每日增加水分攝取至 3 公升
- CMonitor urine specific gravity監測尿液比重
- DAdminister diuretics as ordered依醫囑給予利尿劑
— Explanation · 中文詳解 —
抗利尿激素分泌失調症（SIADH）會導致水分滯留、細胞外液稀釋，進而引發嚴重低血鈉（Hyponatremia）。低血鈉會造成神經系統改變，最嚴重的併發症是腦水腫（Cerebral Edema）導致的癲癇發作或昏迷。因此，對於此類病人，護理師的首要任務是確保神經系統安全與癲癇預防（Seizure Precautions）。
Initiating seizure precautions is the most critical intervention because severe hyponatremia caused by SIADH can lead to cerebral edema and seizures. While monitoring urine specific gravity and administering diuretics are part of the care plan, ensuring client safety from neurological complications takes precedence. Fluid restriction is required, not increased intake.