# 一位82歲女性從長期照護機構轉入，因跌倒住院。其基準簡易智能狀態檢查分數為22/30。住院第2天，她躁動不安、拉扯病袍，並重複說必須搭公車。體溫38.1°C（100.6°F），脈搏104次/分，呼吸22次/分。護理師注意到她今早平靜且對地點有定向力。護理師應首先採取哪兩項行動？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=505792&lang=zh-tw  
> language: zh-TW  
> subject: Psychosocial Integrity  
> category: PSI

## 題目

一位82歲女性從長期照護機構轉入，因跌倒住院。其基準簡易智能狀態檢查分數為22/30。住院第2天，她躁動不安、拉扯病袍，並重複說必須搭公車。體溫38.1°C（100.6°F），脈搏104次/分，呼吸22次/分。護理師注意到她今早平靜且對地點有定向力。護理師應首先採取哪兩項行動？

護理師應首先::선택::收集尿液檢體進行培養及尿液分析給予lorazepam 0.5 mg口服要求緊急神經科會診鼓勵家屬留在床邊和::선택::使用床欄警報器並經常重新定向病人給予lorazepam 0.5 mg口服要求緊急神經科會診鼓勵家屬留在床邊。

## 解析

急性精神狀態改變伴隨注意力波動及思考紊亂，加上發燒與心搏過速，暗示為譫妄。優先處置為找出並治療潛在可逆原因（如感染），並確保安全。收集尿液檢體進行培養及尿液分析，可評估老年人常見的可逆原因（泌尿道感染）。使用床欄警報器並經常重新定向，可在檢查期間維持安全。給予鎮靜劑可能惡化譫妄，並非第一線措施。要求神經科會診在基本評估前為時過早。鼓勵家屬陪伴雖有幫助，但非立即優先於診斷及安全措施。

## 相同主題題目

- [A patient with bipolar I disorder on chronic lithium therapy presents to the ED after seve…](https://mymerci.kr/pages/nclex_q.php?qn_id=372860&lang=zh-tw)
- [A patient with severe contamination obsessive-compulsive disorder is starting exposure and…](https://mymerci.kr/pages/nclex_q.php?qn_id=372864&lang=zh-tw)
- [A 19-year-old patient is admitted with severe anorexia nervosa: BMI 13.5, heart rate 38, B…](https://mymerci.kr/pages/nclex_q.php?qn_id=373260&lang=zh-tw)
- [A 28-year-old woman is at her 6-week postpartum visit. The Edinburgh Postnatal Depression …](https://mymerci.kr/pages/nclex_q.php?qn_id=374202&lang=zh-tw)
- [A patient on a psychiatric inpatient unit is becoming increasingly agitated — pacing, rais…](https://mymerci.kr/pages/nclex_q.php?qn_id=374880&lang=zh-tw)
- [A nurse working in a trauma-informed care (TIC) framework is caring for a patient with a h…](https://mymerci.kr/pages/nclex_q.php?qn_id=374923&lang=zh-tw)
- [A nurse is using motivational interviewing (MI) to help a patient consider changing alcoho…](https://mymerci.kr/pages/nclex_q.php?qn_id=374931&lang=zh-tw)
- [A client on day 7 of unfractionated heparin for DVT shows a platelet drop from 245 to 95 t…](https://mymerci.kr/pages/nclex_q.php?qn_id=374971&lang=zh-tw)

## 以其他語言閱讀

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=505792&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=505792&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=505792&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=505792&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=505792&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。_