護理師對一位高齡病人進行身體評估，哪些發現需要立即進行進一步評估？（選所有適合的）
A nurse is performing a physical assessment on an older adult client. Which finding requires immediate further investigation? (Select all that apply.)
- APresence of a grade 2 skin tear on the forearm前臂出現第二度皮膚撕裂傷
- BA sudden onset of confusion and disorientation✓ 正解突然出現意識混亂和定向力障礙
- CDecreased skin turgor on the clavicle鎖骨處皮膚彈性減退
- DInability to recall the names of two of the three items mentioned 5 minutes ago無法回憶五分鐘前提到的三件物品中的兩件名稱
- EA heart rate of 115 beats per minute while resting✓ 正解休息時心率為每分鐘 115 次
老年病人的急性意識改變（譫妄）常是感染（如 UTI 或肺炎）的警訊；靜止心跳過快可能代表心衰竭、脫水或敗血症，兩者皆為急性生理失衡。皮膚撕裂傷（A）雖需處理但通常非致命，鎖骨處皮膚彈性變差（C）在高齡者為正常老化，短期記憶力輕微缺失（D）若無伴隨功能障礙，需進一步評估但非立即致命。
Acute changes in mental status (delirium) in older adults are often warning signs of infection (such as UTI or pneumonia); resting tachycardia may indicate heart failure, dehydration, or sepsis. Both represent acute physiological derangement. A skin tear (Option A), although it needs care, is usually not life-threatening; decreased skin turgor over the clavicle (Option C) is a normal age-related change; mild short-term memory loss (Option D) requires further evaluation but is not immediately life-threatening if it is not accompanied by functional impairment.
美台皆將譫妄視為急性護理重點，惟台灣臨床對心跳過快或意識改變的評估，往往更依賴護理師的主動偵測。