— 降低風險 · MEDIUM · SATA —
護理師評估一名末梢動脈疾病（PAD）病人，應觀察到哪些特徵？（選所有適合的）
A nurse is performing an assessment on a client with peripheral artery disease (PAD). Which findings should the nurse expect to note? (Select all that apply.)
- AHair loss on the lower extremities✓ 正解下肢毛髮脫落
- BThick, brittle toenails✓ 正解趾甲增厚且易脆
- CUlcers with irregular borders on the ankles踝部有不規則邊緣的潰瘍
- DCool skin temperature of the feet✓ 正解足部皮膚溫度較低
- EIntermittent claudication✓ 正解間歇性跛行
— Explanation · 中文詳解 —
PAD 的特徵為慢性血流不足，表現為間歇性跛行、皮膚冷涼、毛髮脫落、指甲增厚。C 選項屬於靜脈功能不全（Venous Insufficiency）的特徵，與 PAD 不同。護理重點在於評估遠端脈搏與循環狀態。
Peripheral artery disease (PAD) is characterized by chronic insufficient blood flow, resulting in trophic changes such as hair loss, thick brittle toenails, cool skin temperature, and intermittent claudication. These findings distinguish arterial insufficiency from venous issues, where irregular ankle ulcers are typically seen, making the other options the expected assessments for PAD.
✦ 台美臨床差異
台灣對 PAD 病人常會運用 ABI 指數（踝肱指數）進行客觀評估。