# 護理師正在檢閱壓力性損傷紀錄。請點擊根據傷口床可見組織支持第3期分類的橫切面。所有四張插圖均代表壓力相關損傷。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=581192&lang=zh-tw  
> language: zh-TW  
> subject: Reduction of Risk Potential  
> category: ROR

## 題目

護理師正在檢閱壓力性損傷紀錄。請點擊根據傷口床可見組織支持第3期分類的橫切面。所有四張插圖均代表壓力相關損傷。

![](https://mymerci.kr/data/nclex/hotspot/regen_20260908_2350/HSR529.svg)

## 解析

B顯示全層皮膚缺損，暴露皮下脂肪，而肌肉仍被覆蓋。

## 深入解析

快速解答
B。B顯示全層皮膚缺損，暴露皮下脂肪，而肌肉仍被覆蓋。
為何這是最佳選擇
分期分類使用傷口床暴露的組織。在B處，可見黃色分葉狀脂肪，且連續的脂肪層仍將基底與肌肉分開。僅有深坑外觀並不能確立第3期；需辨識其可見組織。
臨床情境
這些觀察數據為虛構的教學資料。請應用所述情境；所選特徵本身不能取代完整的床邊評估。
記憶口訣
辨識暴露的組織；不要透過被遮蔽的傷口床進行分期。
決策規則
辨識暴露的組織；不要透過被遮蔽的傷口床進行分期。
為何其他區域不符合
A顯示暴露的真皮而無脂肪，符合第2期。C暴露肌肉，支持第4期。D基底被遮蔽，從可見表面無法分期；其真實深度無法透過焦痂推斷。
**資料來源**
- NPIAP第3期暴露脂肪而無暴露更深層支持結構；基底被遮蔽則無法分期。

## 重要概念

- **Visible tissue and pressure-injury staging** — 辨識暴露的組織；不要透過被遮蔽的傷口床進行分期。
- **Comparison with context** — C也是全層缺損但暴露肌肉；D隱藏了分期所需的組織。

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