護理師照護一位有跌倒風險的高齡病人。護理計畫中應包含下列哪項措施？
A nurse is caring for an older adult client who is at risk for falls. Which intervention should the nurse include in the plan of care?
- AOrient the client to the environment✓ 正解引導病人熟悉環境
- BApply physical restraints to keep the client in bed對病人實施身體約束以使其留在床上
- CTurn on all room lights only at night僅在夜間開啟房間的所有燈光
- DKeep the bed in the highest position for accessibility將床置於最高位置以便存取
環境熟悉度是預防高齡跌倒的關鍵。帶領病人熟悉環境、放置呼叫鈴於手邊、保持動線淨空，能大幅降低意外。床鋪應維持在最低位；約束會增加病人焦慮且可能導致更嚴重的跌倒（試圖爬出）；照明應全天候維持合適，而非僅限夜晚。
Familiarity with the environment is the key to fall prevention in older adults. Orienting the client to the environment, placing the call light within reach, and keeping the path of travel clear can significantly reduce accidents. The bed should be kept in the lowest position; restraints increase client anxiety and may lead to more severe falls (as the client attempts to climb out); appropriate lighting should be maintained throughout the day, not only at night.
美國醫院廣泛推動『No-Fall Program』，台灣在長照機構較普及，急性病房仍有進步空間。