# 一位老年病患於術後第一天突然變得注意力不集中且定向感混亂。該混亂狀態在班內時好時壞。護理師應首先採取哪項行動？ > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=498500&lang=zh-tw > language: zh-TW > subject: Mental Health Concepts > category: PSI ## 題目 一位老年病患於術後第一天突然變得注意力不集中且定向感混亂。該混亂狀態在班內時好時壞。護理師應首先採取哪項行動？ ## 選項 1. 使用手腕約束帶以防止病患離開床鋪 2. 在完成評估前給予醫囑的鎮靜劑 3. 關燈並限制所有交談直到早晨 4. 立即評估血氧飽和度並尋找可逆原因 **✔ 正確答案** **正確答案: 4** ## 解析 突然發生的波動性注意力不集中符合譫妄的表現。護理師應首先評估並處理可逆的誘發因素，如缺氧、感染、疼痛、藥物、脫水或代謝紊亂。 ## 深入解析 快速解答 評估血氧飽和度並尋找可逆原因。譫妄是一種急性腦功能變化，常表示有潛在的生理問題需要立即矯正。 為什麼這是正確的 突然發作、注意力不集中和波動性可將譫妄與穩定的慢性認知障礙區分開來。缺氧和其他可逆壓力源可能迅速惡化，因此評估應優先於鎮靜或約束措施。 簡單比喻或心智圖像 譫妄就像儀表板上的警示燈：首先要檢查哪個系統出了問題，而不是遮蓋燈光。這個比喻強調了潛在原因，但仍需要結構化的譫妄評估和個別化的安全措施。 記憶掛鉤 急性且波動性的混亂意味著要尋找可逆原因，從氧合狀態開始。 NCLEX 決策規則 當術後混亂突然發生且波動時，應視為譫妄並首先評估生理原因。在支持定向感和安全的同時，避免反射性地使用鎮靜、隔離或約束，除非有特定的立即適應症。 為什麼其他選項是錯的 約束可能加劇躁動和受傷風險。鎮靜可能掩蓋原因，而黑暗和隔離會增加定向感混亂，而非矯正缺氧、感染、藥物影響或代謝問題。參考文獻 - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]NICE: Delirium Prevention, Diagnosis and ManagementNational Institute for Health and Care Excellence ## 相同主題題目 - [A client hospitalized for depression says, "My family would be better off without me." Whi…](https://mymerci.kr/pages/nclex_q.php?qn_id=393687&lang=zh-tw) - [A client with schizophrenia says, "The voices are telling me to do something bad." Which r…](https://mymerci.kr/pages/nclex_q.php?qn_id=394025&lang=zh-tw) - [A client arrives with bruises at different stages of healing. The partner answers all ques…](https://mymerci.kr/pages/nclex_q.php?qn_id=394098&lang=zh-tw) - [A client who stopped heavy alcohol use 24 hours ago is tremulous, diaphoretic, anxious, an…](https://mymerci.kr/pages/nclex_q.php?qn_id=394130&lang=zh-tw) - [A client with anorexia nervosa is admitted with dizziness, heart rate 44/min, and potassiu…](https://mymerci.kr/pages/nclex_q.php?qn_id=394175&lang=zh-tw) - [A client states, "I have a plan to kill myself tonight." Which action is the nurse's prior…](https://mymerci.kr/pages/nclex_q.php?qn_id=396619&lang=zh-tw) - [A client with acute mania is pacing, speaking rapidly, and trying to enter other clients' …](https://mymerci.kr/pages/nclex_q.php?qn_id=397175&lang=zh-tw) - [A client on an inpatient unit is 18 hours after the last alcohol intake and is tremulous, …](https://mymerci.kr/pages/nclex_q.php?qn_id=397292&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=498500&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=498500&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=498500&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=498500&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=498500&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_