護理師進入病房發現病人倒在地上，優先採取的措施為何？
A nurse enters a room and finds a client on the floor. What is the nurse's priority action?
- ANotify the family of the client通知病人家屬
- BAssess the client for injuries✓ 正解評估病人是否有受傷
- CCall for help to assist the client back to bed呼叫協助將病人扶回床上
- DDocument the fall incident in the chart在病歷中記錄跌倒事件
跌倒發生時，護理師的首要任務是進行「損傷評估（Injury Assessment）」。臨床思路遵循 ABC 原則（呼吸、循環、氣道）與安全優先策略，護理師必須先確認病人是否在跌倒過程中遭受致命傷（如顱內出血、脊椎損傷或骨折）。在確認病人生命徵象穩定且無急性損傷前，絕對禁止隨意搬動病人，以免造成二次傷害。後續的協助回床、紀錄與通知屬於評估後的處置階段。
When a fall occurs, the nurse's first task is to perform an injury assessment. The clinical reasoning follows the ABC principle (Airway, Breathing, Circulation) and a safety-first strategy: the nurse must first determine whether the client has sustained any life-threatening injuries during the fall (such as intracranial hemorrhage, spinal injury, or fractures). Before confirming that vital signs are stable and there is no acute injury, the client must absolutely not be moved arbitrarily, to avoid secondary injury. Subsequent steps such as assisting the client back to bed, documentation, and notification belong to the post-assessment phase.
在美國臨床環境中，發生跌倒後必須立即完成「跌倒後評估表（Post-fall Assessment Tool）」，並在電子病歷（EMR）中詳細記錄評估結果，且通常需在 24 小時內完成事故報告（Incident Report），此報告與醫療紀錄分開，不作為懲罰用途。