— 安全與感染控制 · MEDIUM · SATA —
護理師為長期臥床病人制定壓傷（褥瘡）預防計畫。哪些處置是合適的？（選所有適合的）
A nurse is creating a plan to prevent pressure injuries for a bedridden client. Which interventions are appropriate? (Select all that apply.)
- AReposition the client at least every 2 hours✓ 正解至少每2小時為病人翻身一次
- BMassage reddened bony prominences to improve circulation按摩發紅的骨突處以促進循環
- CUse a pressure-redistribution mattress✓ 正解使用減壓或壓力重新分佈床墊
- DKeep the head of the bed elevated above 45 degrees at all times始終將床頭抬高超過45度
- EAssess the skin daily using a standardized tool like the Braden Scale✓ 正解每日使用Braden量表等標準化工具評估皮膚
— Explanation · 中文詳解 —
壓傷預防：每 2 小時翻身、使用減壓床墊、每日執行 Braden 量表評估。B 錯誤：不可按摩紅腫處，這會造成深層組織損傷。D 錯誤：床頭抬高應限制在 30 度以下，以減少剪力（Shear force）對薦骨皮膚的傷害。
Denial serves as a buffer against overwhelming emotional shock, manifesting as refusal to believe the death occurred or statements that the news is a mistake. Clients may also maintain old routines, such as setting a place for the deceased, indicating they have not yet accepted the reality. Anger and social withdrawal are characteristic of different stages of grief, such as anger and depression, respectively.
✦ 台美臨床差異
美台均使用 Braden Scale。美國對「剪力」(Shear force) 的預防（限制床頭高度）在考試中是重點；台灣臨床有時會為了呼吸或餵食而忽略 30 度限制。