護理師進行晨間安全評估時，應優先關注哪些病人？（選所有適合的）
Which of the following clients should the nurse prioritize when performing a morning safety assessment? (Select all that apply.)
- AA client with a history of seizures currently on phenytoin✓ 正解有癲癇病史且目前正在服用苯妥英納的病人
- BA client who is 2 days post-op and has an IV infusion術後第二天且接受靜脈輸液的病人
- CA client with an unsteady gait who is confused✓ 正解步態不穩且意識混亂的病人
- DA client with a history of falls in the past 6 months✓ 正解過去 6 個月內有跌倒史的病人
- EA client who is alert and oriented and independent in ADLs意識清醒、定向力正常且能獨立進行日常生活活動的病人
跌倒風險評估（Fall Risk Assessment）是護理安全的核心。護理師需依據病人的生理狀況、藥物使用及認知功能來評估潛在危險。有癲癇史且服用抗癲癇藥物者（A）、意識不清合併步態不穩者（C），以及近期有跌倒史者（D）皆屬於跌倒高危險群，需列為晨間評估的優先對象。臨床思路應遵循 ABC（氣道、呼吸、循環）後，緊接著就是安全（Safety）評估，以預防病人發生跌倒等醫源性傷害。
Fall-risk prioritization considers medication, cognition, gait, and history. Antiepileptics like phenytoin can cause dizziness and ataxia (A); confusion combined with unsteady gait is a major independent risk factor (C); a documented fall in the past 6 months is the strongest predictor of future falls (D). A routine post-op client with an IV (B) and an alert, independent client (E) are lower priority.
美國醫院廣泛使用 Morse Fall Scale 或 Hendrich II Fall Risk Model 進行量化評估，護理師需精確記錄並執行對應的防跌措施（如標示手環、床欄設置），台灣則多採取類似的跌倒風險評估表，但美國在病歷記錄與跨團隊交班中的強制性規範更為嚴格。