— 基本照護與舒適 · HARD · MCQ —
一位 80 歲病人因脫水入院。哪項評估結果對老年人脫水最可靠？
An 80-year-old client is admitted with dehydration. Which assessment finding is most reliable for dehydration in the elderly?
- ASunken eyes眼窩凹陷
- BSkin turgor on the back of the hand手背皮膚彈性
- CDecreased thirst sensation口渴感減退
- DDryness of the mucous membranes✓ 正解黏膜乾燥
— Explanation · 中文詳解 —
本題旨在考驗護理師對老年人脫水（dehydration）評估的特殊考量。核心概念是老年人因生理老化，其脫水徵象可能與年輕人不同，傳統的評估方法可能不準確。例如，老年人皮膚彈性（skin turgor）因膠原蛋白和彈性纖維流失而自然降低，即使沒有脫水，手背皮膚彈性也可能較差，因此其可靠性降低。相比之下，口腔黏膜（mucous membranes）的濕潤度較不受年齡影響，能更準確地反映細胞內和細胞外液的狀態，因此是評估老年人脫水最可靠的指標之一。
Skin turgor is unreliable in elderly clients due to age-related loss of skin elasticity, which can mimic dehydration signs even when fluid volume is normal. Dryness of the mucous membranes is a more accurate indicator of hydration status in older adults because it is less affected by aging changes.