哪位病人發生皮膚受損的風險最高？
Which client is at the highest risk for developing skin breakdown?
- AA client with an intermittent cough患有間歇性咳嗽的客戶
- BAn ambulatory client with a fractured arm手臂骨折但可行走的客戶
- CA client who is sitting up for lunch坐著吃午餐的客戶
- DA client with decreased sensory perception✓ 正解感覺知覺減弱的客戶
皮膚受損（Pressure Injury）的核心風險因子在於「壓力」與「感知能力」。感覺知覺減弱（如周邊神經病變、脊髓損傷、意識不清）的病人，無法感受到組織缺血引起的疼痛，因此不會產生變換姿勢的保護性動作，導致局部組織長期受壓、微循環受阻而壞死。這題的臨床思路在於識別「病人是否能自主移除壓力源」，感知能力喪失直接剝奪了人體自我保護的機制。
The core risk factors for skin breakdown (pressure injury) are pressure and impaired sensory perception. Patients with diminished sensory perception (such as those with peripheral neuropathy, spinal cord injury, or altered consciousness) cannot perceive the pain caused by tissue ischemia and therefore do not generate protective movements to change position. This results in prolonged pressure on localized tissues, impaired microcirculation, and eventual necrosis. The clinical reasoning here is to identify whether the patient is able to remove the source of pressure on their own; loss of sensory perception directly deprives the body of its self-protective mechanism.