— 照護管理 · MEDIUM · MCQ —
一位護理師正在接收入院一位有跌倒病史的病人。哪項介入措施對預防跌倒最為關鍵？
A nurse is admitting a client with a history of falls. Which intervention is MOST crucial for fall prevention?
- AEncourage the client to ambulate frequently.鼓勵病人經常行走。
- BKeep the side rails up at all times.隨時保持床欄升起。
- CImplement a fall risk assessment and individualized prevention plan.✓ 正解實施跌倒風險評估與個別化預防計畫。
- DPlace the client in a room near the nurses' station.將病人安置在靠近護理站的房間。
— Explanation · 中文詳解 —
跌倒預防並非單一動作，而是一個系統性流程。護理師必須使用標準化評估工具（如 Morse Fall Scale）識別病人的風險因子（如步態不穩、藥物影響、視力減退），並據此制定「個別化」（Individualized）的預防計畫。這種針對性的介入比單純的護理常規（如升起床欄）更有效，能顯著降低跌倒發生率。
Fall prevention is not a single action but a systematic process. The nurse must use a standardized assessment tool (e.g., the Morse Fall Scale) to identify the client's risk factors (e.g., unstable gait, medication effects, decreased vision) and on that basis develop an individualized prevention plan. Such targeted intervention is more effective than generic nursing routines (such as raising the side rails) and significantly reduces the incidence of falls.