哪位病人發生壓瘡（壓力性損傷）的風險最高？
Which client is at the highest risk for developing a pressure injury?
- AAn 80-year-old with incontinence and limited mobility✓ 正解一位80歲且有大小便失禁與活動受限的長者
- BA 50-year-old with diabetes and good nutrition一位50歲且有糖尿病與良好營養狀況的長者
- CA 25-year-old with a spinal cord injury who is physically active一位25歲且具身體活動能力的脊髓損傷患者
- DAn ambulatory 40-year-old with a fractured leg一位40歲且腿部骨折但可行走的長者
壓瘡風險評估（如 Braden Scale）的核心因子包含活動度、感覺能力、濕度與營養。高齡、活動受限且有失禁（潮濕導致皮膚浸潤）的病人，其皮膚完整性受損的機率遠高於其他選項。A 可行走，B 有良好營養保護，C 雖有脊髓損傷但若活動度高可代償，均不如 A 風險高。
Pressure injury risk assessment (such as the Braden Scale) considers core factors including mobility, sensory perception, moisture, and nutrition. Older clients with limited mobility and incontinence (causing skin moisture and maceration) are at far greater risk of impaired skin integrity than the other options. Option D is ambulatory, option B has good nutritional protection, and option C, although having a spinal cord injury, can compensate with high activity; none carries the same level of risk as option A.
Branden Scale 是美台醫院皆廣泛使用的壓瘡風險評估工具，護理紀錄中皆要求定期評估。