— 安全與感染控制 · MEDIUM · MCQ —
護理師照顧一位有跌倒史的病人。哪項護理干預是優先的？
A nurse is caring for a client with a history of falls. What is the priority nursing intervention?
- APlacing the call light within reach✓ 正解將呼叫鈴放在病人可觸及之處
- BAssigning a sitter to stay in the room 24/7指派專人 24 小時守在病房
- CKeeping the patient on strict bed rest讓病人嚴格卧床休息
- DApplying a physical restraint to the patient對病人實施身體約束
— Explanation · 中文詳解 —
跌倒防護首重維持病人安全感與獨立性，且採取「限制最少（Least Restrictive）」的原則。放置呼叫鈴（A）是鼓勵病人求援最基礎的措施。約束（D）與長期臥床（C）會導致病人功能退化；專人看顧（B）資源消耗大，非優先考量。
Fall prevention prioritizes maintaining the patient's sense of safety and independence, while adopting the 'least restrictive' principle. Placing a call light (A) is the most basic measure to encourage the patient to call for help. Restraints (D) and prolonged bed rest (C) lead to functional decline; one-on-one sitters (B) consume significant resources and are not the priority.
✦ 台美臨床差異
台美皆提倡限制約束（Restraint-free）概念，呼叫鈴使用率在美國醫院受監測，台灣亦逐漸重視。