護理師正在照顧一位有跌倒病史且服用苯二氮平類藥物(benzodiazepine)的病人。下列哪項評估發現需要立即介入?
A nurse is caring for a client with a history of falls who is taking a benzodiazepine. Which assessment finding requires immediate intervention?
- AClient's respiratory rate is 14 breaths/min病人呼吸速率為每分鐘 14 次
- BClient reports feeling tired病人主訴感到疲倦
- CClient's gait is unsteady✓ 正解病人步態不穩
- DClient's blood pressure is 100/60 mmHg病人血壓為 100/60 mmHg
苯二氮平類藥物(Benzodiazepines)具有中樞神經抑制作用,常見副作用包括鎮靜、肌力減弱及步態不穩。對於有跌倒病史的病人,這類藥物會顯著增加再次跌倒的風險。評估發現中若出現步態不穩,代表病人的平衡與協調能力受損,屬於發生跌倒的高危險徵兆,護理師必須立即介入,例如協助移位、加強安全監測或與醫療團隊討論調整用藥。
Benzodiazepines have a central nervous system depressant effect; common side effects include sedation, reduced muscle strength, and unsteady gait. In a patient with a history of falls, these drugs significantly increase the risk of recurrent falls. If unsteady gait is noted on assessment, it indicates impaired balance and coordination and represents a high-risk warning for falls; the nurse must intervene immediately, for example by assisting with transfers, intensifying safety monitoring, or discussing medication adjustment with the medical team.