護理師為一位膚色較深的病人進行皮膚評估。下列哪個部位最能準確觀察到發紺（Cyanosis）？
A nurse is performing a skin assessment on a client with dark skin. Which location is most reliable for identifying cyanosis in this client?
- AThe soles of the feet足底
- BThe nail beds指甲床
- CThe earlobes耳垂
- DThe conjunctivae結膜正確答案
- D結膜
對於膚色較深的病人（Dark-skinned clients），由於皮膚黑色素較多，觀察皮膚表面的顏色變化（如發紺、蒼白或黃疸）會受到干擾。因此，護理師應評估色素沉著較少、黏膜較薄且血管分佈豐富的部位。結膜（Conjunctivae）、口腔黏膜（Oral mucosa）以及硬顎（Hard palate）是最可靠的觀察點。選項 C 耳垂與 B 指甲床在深膚色者身上常因天然色素干擾而出現偽陽性或隱藏發紺；A 選項足底皮膚較厚，觀察不夠靈敏。這題強調護理評估的「文化敏感度」與「生理變異知識」，是跨文化照護的基礎概念。
- A足底
腳底皮膚通常角質層較厚，且血液循環末梢較遠，顏色反映不夠靈敏，且厚皮會阻礙對深層血管顏色的視覺判斷。
- B指甲床
深膚色者的指甲床常有天然的黑色素帶或色素沉著，這會遮蓋發紺導致的青紫色，因此並非評估缺氧的最佳部位。
- C耳垂
耳垂的皮膚厚度與黑色素分佈不均，在深膚色病人身上觀察發紺的效果極差，容易產生誤判，不具備臨床診斷的可靠性。
- D · 正確答案結膜
黏膜組織受黑色素影響最小。觀察結膜或口腔黏膜的顏色變化，能最直接反映血液中去氧血紅素的濃度，是深膚色病人的標準評估點。
美國 NCLEX 針對「深膚色病人評估」有非常多題目，反映其多民族社會的特性。台灣護理教育過去較少強調此點，但隨著新住民與外籍病患增加，護理師需學習辨識非典型皮膚徵象的精確評估部位。
English explanation
In dark-skinned clients, the increased amount of melanin in the skin interferes with the observation of surface color changes such as cyanosis, pallor, or jaundice. Therefore, the nurse should assess sites with less pigmentation, thin mucous membranes, and rich vascular distribution. The conjunctivae, oral mucosa, and hard palate are the most reliable observation sites. Options A (earlobes) and B (nail beds) in dark-skinned clients often have natural pigmentation that may cause false positives or mask cyanosis; option A (soles of the feet) has thicker skin that makes observation less sensitive. This question emphasizes "cultural sensitivity" and "knowledge of physiological variation" in nursing assessment, which is foundational to cross-cultural care.
最近修訂：2026-10-06