— 安全與感染控制 · MEDIUM · SATA —
護理師為一位高齡病人進行跌倒風險評估。哪些因素會增加跌倒風險？（選所有適合的）
A nurse is conducting a fall risk assessment on an elderly client. Which factors increase the risk for falls? (Select all that apply.)
- AHistory of recent falls✓ 正解曾有跌倒病史
- BUse of antihypertensive medications✓ 正解使用抗高血壓藥物
- CUse of assistive devices like a cane✓ 正解使用枴杖等輔具
- DPresence of urinary urgency✓ 正解有尿急症狀
- EImproved muscle strength in lower extremities下肢肌肉力量改善
— Explanation · 中文詳解 —
跌倒風險評估（Morse Fall Scale 等）包含：跌倒病史、藥物（血壓藥導致姿勢性低血壓）、輔具（顯示步態不穩）、急迫性尿意（病人急於如廁而忽略安全）。選項 E 肌肉力量增強是保護因子，不屬於風險因子。
Fall risk assessments (such as the Morse Fall Scale) include: history of falls, medications (antihypertensives causing orthostatic hypotension), use of assistive devices (indicating unstable gait), and urinary urgency (the client rushes to the toilet and overlooks safety). Option E, improved muscle strength, is a protective factor and not a risk factor.
✦ 台美臨床差異
美國醫院廣泛使用 Morse Fall Scale；台灣則多使用醫院自行訂定之跌倒危險因子評估表。