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降低風險 · MEDIUM · SATA

護理師正在照顧一位有跌倒病史的病人。該病人被處方一種新的利尿劑。下列哪些措施可以最大限度地降低與此藥物相關的跌倒風險?(選所有適合的)

A nurse is caring for a client with a history of falls. The client is prescribed a new diuretic. Which of the following actions should the nurse take to minimize the risk of falls related to this medication? (Select all that apply.)

  • AMonitor the client's blood pressure before and after ambulation✓ 正解
    監測病人步行前後的血壓
  • BInstruct the client to rise slowly from bed✓ 正解
    指導病人從床上緩慢起身
  • CEncourage the client to drink large amounts of fluid
    鼓勵病人大量飲水
  • DEnsure the client has a clear path to the bathroom✓ 正解
    確保通往洗手間的通道暢通無阻
  • EAdminister the medication in the morning✓ 正解
    於早晨給藥
Explanation · 中文詳解

利尿劑(diuretics)會增加尿量並可能導致體液容積減少,進而引發姿勢性低血壓(orthostatic hypotension),這是高跌倒風險病人的主要威脅。護理重點在於預防血壓驟降導致的頭暈,並減少夜間如廁需求。正確選項均旨在降低環境風險或透過行為調適來減少跌倒發生率。臨床思路應優先考慮預防病人血流動力學不穩定及環境障礙。

Diuretics increase urine output and can decrease fluid volume, leading to orthostatic hypotension, the main threat to a client at high risk of falls. Nursing care focuses on preventing dizziness from a sudden drop in blood pressure and reducing nocturia. The correct options all aim to lower environmental risks or use behavioral modification to reduce the incidence of falls. The clinical reasoning is to prioritize preventing hemodynamic instability and removing environmental hazards.

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