— 基本照護與舒適 · MEDIUM · MCQ —
一位病人有皮膚完整性受損的風險。哪項護理行動能有效應對？
A client is at risk for impaired skin integrity. Which nursing action effectively addresses this?
- APosition the client on their bony prominences將病人置於骨突處
- BKeep the linens clean, dry, and wrinkle-free✓ 正解保持床單清潔、乾燥且無皺褶
- CLimit protein intake to avoid skin irritation限制蛋白質攝取以避免皮膚刺激
- DUse circular massage to promote circulation使用環狀按摩促進循環
— Explanation · 中文詳解 —
皮膚完整性受損（Impaired skin integrity）的風險管理重點在於減少機械性壓力與摩擦。保持床單乾淨、平整且乾燥，能避免皮膚受到皺褶產生的剪力（Shearing force）傷害及潮濕引起的浸潤（Maceration）。其他的選項如按摩骨突處，根據實證醫學，會對皮下組織造成更嚴重的損傷，因此應嚴格禁止。
Management of impaired skin integrity risk centers on reducing mechanical pressure and friction. Keeping linens clean, smooth, and dry helps avoid shearing injury from wrinkles and maceration from moisture. Other options, such as massaging bony prominences, have been shown by evidence-based practice to cause deeper tissue injury and are strictly contraindicated.