— 基本照護與舒適 · MEDIUM · MCQ —
護理師為高齡病人進行清潔護理時，哪項發現需優先處理？
A nurse is providing hygiene care for an older adult client. Which finding requires immediate nursing attention during the bath?
- APresence of dry, scaly skin on the lower legs小腿出現乾燥、鱗屑狀皮膚
- BCalluses on the plantar aspect of the feet足底有老繭
- CA small, intact blister on the heel✓ 正解足跟有一個小而完整的水泡
- DRedness over the sacral area that blanches on pressure薦骨區域發紅，按壓後褪色
— Explanation · 中文詳解 —
高齡者皮膚脆弱，足跟水泡（即使完整）代表局部壓力已達傷害程度。選項 A 為常見老化現象；選項 D 之紅斑若能退色，代表循環尚可，屬於 Stage 1 的邊緣狀態，需加強減壓而非立即處理；選項 B 為長期受力後的角質化，非急性威脅。
Elderly skin is fragile, and a blister on the heel—even when intact—indicates that local pressure has reached an injurious level. Option A is a common manifestation of aging. The blanchable erythema in Option D indicates that circulation is still preserved and represents a borderline Stage 1 finding requiring enhanced pressure relief rather than immediate intervention. Option B represents chronic keratinization due to long-term loading and is not an acute threat.
✦ 台美臨床差異
無明顯差異，皆強調預防壓傷為護理重點。