— 基本照護與舒適 · MEDIUM · MCQ —
對於一位臥床病人，哪項評估最重要以預防併發症？
Which assessment is most important to prevent complications for a client on bed rest?
- AMonitoring the client's hair growth監測病人的毛髮生長
- BChecking the room temperature every hour每小時檢查室溫
- CMeasuring the distance between the bed and the door測量床與門之間的距離
- DAssessing skin integrity at pressure points✓ 正解評估壓力點的皮膚完整性
— Explanation · 中文詳解 —
臥床病人最大的風險是壓瘡（Pressure Injury）。評估皮膚完整性（D），特別是骨突處（如骶尾部、腳跟、肩胛骨），是護理師的臨床關鍵任務。早期發現皮膚紅斑（Stage 1）並及時介入（如翻身、減壓），可防止潰瘍形成。室溫（B）虽需舒適但非防範併發症的關鍵；頭髮生長（A）與醫療併發症無關；床與門的距離（C）與病人照護安全無關。
Clients on bed rest are at high risk for pressure injuries due to immobility. Assessing skin integrity at pressure points, such as the sacrum, heels, and scapulae, is the most critical intervention to detect early signs like Stage 1 redness. Early detection allows for timely interventions like repositioning and pressure relief to prevent ulcer formation. Other factors like hair growth or room temperature are not primary clinical priorities for preventing immobility-related complications.