# 一位急性躁症個案正在踱步、說話急促，並試圖進入其他個案的房間。哪種護理措施最合適？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397174&lang=zh-tw  
> language: zh-TW  
> subject: Mental Health Concepts  
> category: PSI

## 題目

一位急性躁症個案正在踱步、說話急促，並試圖進入其他個案的房間。哪種護理措施最合適？

## 選項

1. 鼓勵個案主持大型團體討論。
2. 提供關於雙相情緒障礙症的詳細書面衛教。
3. 除非有其他個案抱怨，否則忽略該行為。
4. 使用平靜、簡短的指示並設定明確的限制。 **✔ 正確答案**

**正確答案: 4**

## 解析

急性躁症個案常有注意力分散、界線不佳和活動量增加的情形。平靜、簡短的溝通和明確的限制有助於維護安全並減少刺激。在急性發作期間，大型團體、詳細衛教和忽略界線侵犯行為並非治療性措施。

## 深入解析

臨床判斷
使用個案線索、時機、檢驗數據和安全風險，選擇最適合急性躁症設限的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX考題獎勵基於線索的優先思考，而非孤立記憶。

## 臨床情境

臨床實務指引
對於急性躁症設限，將完整的線索模式與個案當前的穩定性、醫囑數據和預期的護理範圍進行比較。

注意
當完整情境改變了優先順序或安全性時，不要僅根據一個孤立的線索選擇行動。

## 重要概念

- **躁症** — 一種情緒狀態，特徵為情緒高昂或易怒、精力增加和判斷力受損。
- **設限** — 用於維護安全和結構的明確、一致界線。
- **低刺激環境** — 減少感官輸入的環境，有助於降低情緒升級。

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