— 基本照護與舒適 · EASY · MCQ —
護理師評估一位病人的個人衛生能力。哪項觀察顯示病人需要協助？
A nurse is evaluating a client's ability to maintain personal hygiene. Which observation indicates the client needs assistance?
- AThe client combs hair with ease個案輕鬆地梳理頭髮
- BThe client manages buttoning clothes without help個案無需協助即可扣好衣服鈕扣
- CThe client brushes teeth independently個案獨立刷牙
- DThe client is unable to reach their back during a bath✓ 正解個案在洗澡時無法觸及背部
— Explanation · 中文詳解 —
個人衛生評估是日常生活活動（ADLs）的一部分。護理師應評估病人的功能性獨立程度。若病人能自行刷牙、梳頭、扣鈕扣，代表手部精細動作與上肢關節活動度（ROM）正常。無法觸及背部沐浴，則顯示肩關節活動受限或身體靈活度不足，這不僅影響清潔，還可能引發皮膚問題。護理師需針對此缺失提供協助，並評估是否需要復健或輔助工具，以維持病人的基本自理能力。
The inability to reach the back during bathing indicates limited range of motion or flexibility, suggesting the client requires assistance with activities of daily living. Independence in tasks like combing hair, dressing, and brushing teeth demonstrates adequate functional status, whereas restricted movement compromises hygiene and skin integrity.