— 照護管理 · HARD · SATA —
護理師評估懷疑受虐的病人，哪些發現應紀錄為潛在指標？（選所有適合的）
A nurse is assessing a client for signs of abuse. Which findings should the nurse document as potential indicators? (Select all that apply.)
- AInjuries in various stages of healing✓ 正解處於不同癒合階段的傷害
- BA client who avoids eye contact while the caregiver answers all questions✓ 正解當照護者回答所有問題時，病人避免眼神接觸
- CBruising on the inner arms and thighs✓ 正解手臂內側和大腿出現瘀傷
- DConsistent physical findings with the reported explanation of injury身體檢查結果與報告的受傷原因一致
- EThe client expresses fear when the caregiver enters the room✓ 正解當照護者進入房間時，病人表達恐懼
— Explanation · 中文詳解 —
受虐的臨床徵象包括：傷口呈現不同癒合階段（顯示重複傷害）、照護者包辦回答、受傷部位位於非防禦性區域（如內側肢體）、病人對於照護者出現表現出明顯恐懼。若傷口發現與敘述一致，則通常指向意外，不屬於受虐指標。
Potential indicators of abuse include injuries in various stages of healing, bruising in protected areas like the inner thighs, and controlling behavior by caregivers who answer for the client. Additionally, a client expressing fear when a caregiver enters the room is a significant red flag. Consistent explanations for injuries typically suggest accidental causes rather than abuse.
✦ 台美臨床差異
美國對強制通報（Mandatory Reporting）之法律責任極為嚴格；台灣護理師亦需依性侵害或家暴防治法通報。