A nurse is caring for a client with autosomal dominant polycystic kidney disease (ADPKD). Which nursing intervention is most appropriate to help prevent complications associated with this condition?

1 Encourage high-protein diet to maintain muscle mass
2 Restrict fluid intake to 1000 mL per day
3 Monitor and control blood pressure within target range ✓ 정답
4 Administer diuretics to reduce kidney workload

해설

Blood pressure control is critical in ADPKD to slow disease progression and prevent cardiovascular complications. Other options are not recommended as they may worsen outcomes.

심화 해설

護理學核心解析 核心概念分析 (Key Concept)：這題在考驗對自體顯性多囊性腎病 (Autosomal Dominant Polycystic Kidney Disease, ADPKD) 核心護理目標的理解。ADPKD 是一種遺傳性疾病，腎臟會長出許多囊腫，導致腎實質被破壞，最終進展為末期腎病變 (ESRD)。其病理機制的關鍵在於囊腫的增長會壓迫腎組織，引發腎素-血管張力素-醛固酮系統 (RAAS) 過度活化，導致高達 80% 的患者出現核心！高血壓 (Hypertension)。而高血壓本身又會加速腎絲球損傷，形成惡性循環。

正確答案依據 (Answer Rationale)：核心！目前實證醫學對於 ADPKD 最關鍵、最有效的延緩疾病進展措施，就是積極的血壓控制 (Blood pressure control)。目標血壓通常設定在

임상 시나리오

護理臨床實務指南 臨床情境 (Clinical Scenario)：門診來了一位 38 歲的張先生，新診斷為 ADPKD，他有家族史（父親於 50 多歲開始洗腎）。目前血壓 148/92 mmHg，血清肌酸酐輕微上升，自述偶有腰痠。他非常焦慮，詢問：「護理師，我該怎麼做才不會那麼快就要洗腎？」

護理處置策略 (Nursing Intervention)： 1. 評估 (Assessment)：詳細評估血壓監測習慣、用藥遵從性、飲食內容（特別是鹽分與蛋白質攝取）、水分攝取、疼痛狀況、以及對疾病的認知與情緒反應。
2. 護理目標設定 (Goal Setting)：短期目標為病人能說出控制血壓的重要性，並示範正確血壓量測技巧。長期目標為將血壓穩定控制在

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A nurse is caring for a client with autosomal dominant polycystic kidney disease (ADPKD). Which nursing intervention is most appropriate to help prevent complications associated with this condition?

심화 해설

임상 시나리오

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