— 照護管理 · MEDIUM · MCQ —
一位老年病人意識混亂並試圖爬下床，護理師首要介入措施為何？
An elderly client is confused and attempting to climb out of bed. What is the priority nursing intervention?
- AAdminister a sedative to keep the client quiet給予鎮靜劑以保持病人安靜
- BProvide a sitter or place the client close to the nurse's station✓ 正解安排專人看護或將病人安置於護理站附近
- CApply physical restraints immediately立即施加身體約束
- DLower the bed to the lowest position and leave the room將病床降至最低位置並離開房間
— Explanation · 中文詳解 —
預防跌倒是急性病房的核心安全指標。優先應採取『限制最小化』措施，如增加觀察頻率、安排專人看護（Sitter）或調動床位至護理站旁，而非直接使用約束（Restraints）或給予鎮靜劑（化學約束），因為這些手段可能加劇混亂。
Fall prevention is a core safety indicator on acute care units. The least restrictive measures should be prioritized, such as increased observation frequency, assigning a one-to-one sitter, or moving the client closer to the nurses' station, rather than immediately applying physical restraints or sedatives (chemical restraint), as these can worsen confusion.
✦ 台美臨床差異
美國『約束減量』法規嚴格；台灣在臨床實務中，照護人力不足時，約束常被過度使用，需加強預防跌倒的非侵入性策略。