護理師照護一位活動受限的病人。為了預防併發症，護理計畫應包含下列哪些？（選所有適合的）
A nurse is caring for an immobile client. To prevent complications, what should the nurse include in the care plan? (Select all that apply.)
- APassive range-of-motion exercises✓ 正解被動關節活動運動
- BEncouraging high protein intake✓ 正解鼓勵高蛋白飲食
- CAssessing lung sounds every shift✓ 正解每班次評估肺部呼吸音
- DLimiting fluid intake to prevent incontinence限制水分攝取以預防失禁
- EFrequent skin assessments✓ 正解頻繁進行皮膚評估
對於長期活動受限（Immobile）的病人，護理目標在於預防併發症如關節攣縮、廢用性肌萎縮、皮膚破損及肺炎。核心護理措施應包含：被動關節活動度運動（PROM）以維持關節功能；高蛋白飲食以修復組織與維持肌肉量；定期評估呼吸音以早期偵測肺部積液或肺炎徵兆；以及頻繁的皮膚評估以預防壓瘡。臨床思路應優先考慮預防不動帶來的負面影響，並採取多方面的預防策略。
Care plans for immobile clients should prioritize preventing complications such as joint contractures, muscle wasting, pressure injuries, and hypostatic pneumonia. Appropriate interventions include performing passive range-of-motion exercises, encouraging high-protein intake to support tissue repair, frequently assessing skin integrity, and monitoring lung sounds every shift.
在美國臨床實務中，對於長期臥床病人的預防性護理（如預防壓瘡、PROM）非常強調跨專業照護（Interdisciplinary care），物理治療師（PT）通常會參與並制定運動計畫，護理師則負責執行與監測。