— 照護管理 · MEDIUM · MCQ —
護理師照護一位有跌倒病史的病人，哪項行動最展現「預防跌倒」的優先性？
A nurse is caring for a client with a history of falls. Which action best demonstrates the nurse's priority in preventing future falls?
- AKeeping the bed rail up at all times始終保持床欄拉起
- BCompleting a thorough fall risk assessment and developing a care plan✓ 正解完成詳細的跌倒風險評估並制定照護計畫
- CAssigning the UAP to assist the client with every movement指派護佐協助病人每次移動
- DPutting the client in a wheelchair to ensure they don't walk讓病人坐在輪椅上以確保其不行走
— Explanation · 中文詳解 —
跌倒預防的核心在於個別化的評估與計畫（Individualized care plan）。透過完整的風險評估（如 Morse Fall Scale），護理師能制定針對性的照護策略。單純使用床欄或限制行動，反而可能影響病人的活動能力並造成其他併發症。
The core of fall prevention is an individualized assessment and care plan. By performing a comprehensive risk assessment (such as the Morse Fall Scale), the nurse can develop targeted strategies. Simply using side rails or restricting movement may actually impair the client's mobility and cause other complications.
✦ 台美臨床差異
美台對 Morse Fall Scale 等量表的應用皆相當普遍，是評估病人的標準流程。