護理師正在評估病人的跌倒風險。哪項因素最顯著地增加高齡病人的跌倒風險？
The nurse is assessing a client's risk for falls. Which factor most significantly increases the risk of falling in an elderly client?
- AHistory of a fall within the past 3 months.✓ 正解過去 3 個月內有跌倒史。
- BLiving with a spouse.與配偶同住。
- CUse of corrective eyeglasses.使用矯正眼鏡。
- DWearing non-skid socks.穿著止滑襪。
「過去的跌倒史」是預測未來跌倒最強大的指標。根據 Morse Fall Scale 等評估表，曾有跌倒紀錄者風險最高。矯正眼鏡（C）和止滑襪（D）是降低風險的因素；與配偶同住（B）通常提供社會支持與監測，風險較獨居低。護理師應針對高風險者採取積極措施，如床欄使用、呼叫鈴觸手可及與頻繁巡房。
A history of previous falls is the single strongest predictor of future falls. On assessment tools such as the Morse Fall Scale, clients with a prior fall carry the highest risk. Corrective eyeglasses (C) and non-skid socks (D) are protective factors that reduce risk; living with a spouse (B) usually provides social support and monitoring, conferring a lower risk than living alone. For high-risk clients, the nurse should institute active measures such as side-rail use, keeping the call light within reach, and frequent rounding.
美國 NCLEX 非常強調「Safety and Infection Control」，跌倒是核心考點；台灣醫院則常用「跌倒高風險標示」於床頭。