— 照護管理 · MEDIUM · MCQ —
護理師督導助手照顧中風病人，助手哪項行為需立即介入？
A nurse is supervising an assistive personnel (AP) providing care to a client with a stroke. Which action by the AP requires immediate nurse intervention?
- APositioning the client on the affected side for 3 hours✓ 正解將病人置於患側臥位 3 小時
- BFeeding the client with the head of the bed elevated to 30 degrees將床頭抬高 30 度餵食病人
- CAssisting the client with ambulation using a gait belt使用步態帶協助病人步行
- DRemoving the client's dentures to perform oral hygiene移除病人假牙以進行口腔清潔
— Explanation · 中文詳解 —
中風（Stroke）病人的照護重點在於預防患側（Affected side）的皮膚損傷與關節攣縮。患側由於感覺喪失或減弱，無法感知壓迫，長時間固定於同一側會導致組織缺血、壓瘡形成。護理師需確保助手遵守翻身頻率（通常每 2 小時一次）並避免直接壓迫患側。此題考查的是護理師對助理人員的督導責任，對於危害病人安全的行為，必須立即介入以維護病人權益。
Positioning the client on the affected side for three hours requires immediate intervention because prolonged pressure on the hemiplegic side significantly increases the risk of pressure ulcers and nerve compression. Since sensation is often impaired on the affected side, the client cannot perceive the discomfort, making frequent repositioning every two hours essential to prevent tissue ischemia.