護理師為一位高齡病人進行跌倒風險評估，下列哪些情況顯示跌倒風險升高？（選所有適合的）
A nurse is conducting a fall risk assessment for an elderly client. Which of the following findings indicate an increased risk of falls? (Select all that apply.)
- AHistory of a previous fall in the last 6 months✓ 正解過去6個月內有跌倒史
- BUse of antihypertensive medications✓ 正解使用抗高血壓藥物
- CPresence of orthostatic hypotension✓ 正解存在姿勢性低血壓
- DCognitive impairment✓ 正解認知功能障礙
- EIndependent use of a quad cane獨立使用四腳拐杖
跌倒風險評估指標包含過去病史、藥物影響與生理狀態。曾有跌倒史、使用降血壓藥造成姿勢性低血壓、以及認知功能受損，皆為公認的跌倒高風險因子。選項 E 中使用四腳拐杖顯示病人具備步行輔助能力，且若能正確使用，通常被視為增加穩定性的保護因子，而非風險增加因子。
Indicators of fall risk include past history, medication effects, and physiological status. Previous falls, use of antihypertensives causing orthostatic hypotension, and cognitive impairment are all well-established high-risk factors for falling. In option E, use of a quad cane indicates that the client has a walking aid, and when used correctly it is generally considered a protective factor that improves stability rather than a risk factor.
美國醫院多採用 Morse Fall Scale 或 Hendrich II 模型，台灣則多使用簡化的跌倒風險評估表。