護理師協助一位高齡病人進行晨間護理，該病人右肩活動度受限。優先採取的護理措施為何？
A nurse is preparing to assist an elderly client with morning hygiene. The client has limited range of motion in the right shoulder. What is the priority nursing intervention?
- AUndress the client starting with the right arm first先從右臂開始為病人脫衣
- BComplete all bathing tasks for the client to save their energy為病人完成所有洗澡工作以節省體力
- CInstruct the client to wash their own face while the nurse washes the back指示病人自行洗脸，同時護理師為病人擦背
- DUndress the client starting with the left arm first✓ 正解先從左臂開始為病人脫衣
晨間護理協助穿脫衣的標準原則是「脫健側先、穿患側先」（undress unaffected side first, dress affected side first）。脫衣時從健側（unaffected side）先脫，可避免不必要拉扯患側；穿衣則反之，從患側（affected side）先穿，讓健側最後再穿過袖子。本題病人右肩活動受限（右側為患側），脫衣應先脫左側（健側），故正確答案為 D。選項 A 先脫患側會強迫受限關節大幅度活動造成不適與疼痛，是錯誤動作。
The standard principle when assisting with dressing and undressing during morning care is 'undress the unaffected side first, dress the affected side first.' When undressing, starting from the unaffected side avoids unnecessary pulling on the affected limb; when dressing, the reverse order is used, putting the affected side through the sleeve first so that the unaffected side is dressed last. In this scenario, the patient has limited mobility in the right shoulder (right side is the affected limb), so undressing should begin with the left (unaffected) side, making option D correct. Option A, undressing the affected side first, forces the limited joint through a large range of motion and causes pain, which is incorrect.
台美臨床對於ADL（日常生活活動）訓練概念一致，強調殘存功能之最大化。