— 基本照護與舒適 · MEDIUM · SATA —
照顧臥床病人時，護理師應監測哪些壓瘡發展的徵兆？（選所有適合的）
Which signs of pressure injury development should a nurse monitor for when caring for a bedridden client? (Select all that apply.)
- ANon-blanchable erythema on bony prominences✓ 正解骨突處出現按壓不褪色的紅斑
- BSkin temperature changes✓ 正解皮膚溫度變化
- CLocalized edema✓ 正解局部水腫
- DIncreased hair growth毛髮生長增加
- EInduration of the skin✓ 正解皮膚硬化
— Explanation · 中文詳解 —
壓瘡（Pressure Injury）的形成與局部缺血有關。護理師應評估骨突處（Bony prominences）的皮膚變化。關鍵徵兆包括紅斑（Erythema）且按壓不褪色（Non-blanchable）、皮膚溫度變異、局部水腫及質地變硬（Induration）。這些反映了組織受壓後的發炎與受損反應。毛髮生長與壓瘡無關，為干擾選項。
Pressure injury formation is related to localized ischemia. The nurse should assess skin changes over bony prominences. Key signs include non-blanchable erythema, changes in skin temperature, localized edema, and induration. These reflect the inflammatory and injury response of tissue subjected to pressure. Hair growth is unrelated to pressure injury and serves only as a distractor.