— 安全與感染控制 · MEDIUM · SATA —
下列哪些評估結果顯示病人的身體約束可能造成傷害？（選所有適合的）
Which assessment findings indicate that a client's physical restraints are causing harm? (Select all that apply.)
- AThe client's hands are cool to the touch✓ 正解病人的雙手觸摸起來冰冷
- BCapillary refill time is 2 seconds毛細血管回填時間為 2 秒
- CThe client is unable to move fingers✓ 正解病人無法移動手指
- DA new area of skin breakdown is observed✓ 正解觀察到新出現的皮膚破損區域
- EPeripheral pulses are absent✓ 正解周邊脈搏消失
— Explanation · 中文詳解 —
身體約束（Physical Restraints）必須定期評估以預防併發症。評估重點包括約束部位的血液循環（脈搏、顏色、溫度、微血管回填時間）以及神經功能（感覺、運動能力）。肢體冰冷、脈搏消失、無法活動及皮膚破損均為嚴重警訊，顯示約束帶過緊或位置不當，可能導致組織缺血、壞死或神經損傷，必須立即鬆開並重新評估。
Cool extremities, absent peripheral pulses, inability to move fingers, and new skin breakdown indicate compromised circulation, nerve damage, or tissue injury caused by the restraints. These findings require immediate intervention to loosen or remove the restraints to prevent permanent harm such as ischemia or necrosis.