— 基本照護與舒適 · MEDIUM · MCQ —
護理師評估一位薦骨有第二級壓瘡的病人，下列何者為預期發現？
A nurse is assessing a client with a Stage 2 pressure ulcer on the sacrum. Which finding is expected?
- AFull-thickness skin loss with visible bone全層皮膚缺失伴隨可見骨頭
- BFull-thickness tissue loss with necrotic eschar全層組織缺失伴隨壞死焦痂
- CPartial-thickness loss of dermis presenting as a shallow open ulcer✓ 正解真皮部分缺失呈現為淺表開放性潰瘍
- DIntact skin with non-blanchable redness皮膚完整但有不可褪色之紅斑
— Explanation · 中文詳解 —
壓瘡（Pressure Ulcer）的分級依據 NPUAP（National Pressure Ulcer Advisory Panel）標準。第二級壓瘡（Stage 2）的定義為部分真皮層缺失（partial-thickness loss of dermis），外觀呈現淺粉紅色、無腐肉的潰瘍，或是完整或破裂的漿液性水泡（serum-filled blister）。此階段需保護傷口，防止惡化。
A Stage 2 pressure ulcer is characterized by partial-thickness loss of the dermis, appearing as a shallow open ulcer or a serum-filled blister. This differs from Stage 1, which presents as intact skin with non-blanchable redness.