— 生理適應 · HARD · MCQ —
一位尿崩症（DI）病人。哪項護理行動優先？
A client presents with signs of diabetes insipidus. Which nursing intervention is the priority?
- ARestrict fluid intake限制水分攝取
- BMonitor for signs of fluid volume deficit✓ 正解監測體液不足跡象
- CMaintain a low-sodium diet維持低鈉飲食
- DAdminister potassium supplements給予鉀補充劑
— Explanation · 中文詳解 —
尿崩症（Diabetes insipidus, DI）是因為抗利尿激素（ADH）分泌不足，導致腎小管無法再吸收水分，病人會排出大量稀釋尿液。護理師的首要任務是監測體液流失狀況，包括嚴格測量進出量（I&O）、體重與生命徵象（如心跳加快、血壓下降）。若未及時補充水分，病人極易進入脫水性休克，因此絕不可限制水分。
The priority nursing intervention is to monitor for signs of fluid volume deficit, as excessive urination in DI can rapidly lead to life-threatening dehydration and shock. Strict intake and output monitoring, along with assessing vital signs and weight, is essential to guide fluid replacement therapy.