— 基本照護與舒適 · MEDIUM · MCQ —
護理師照護一位有跌倒病史的病人，規劃照護計畫時，下列哪項為最高優先級？
A nurse is caring for a client with a history of falls. Which action is the highest priority when planning care?
- AInstructing the family to stay with the client指示家屬留在病人身邊
- BConducting a comprehensive fall risk assessment✓ 正解進行全面的跌倒風險評估
- CKeeping the bed in the lowest position將病床保持在最低位置
- DPlacing a bed alarm on the client's bed在病人床上放置床邊警報器
— Explanation · 中文詳解 —
護理程序應以評估（Assessment）為首。必須先進行全方位的跌倒風險評估（如 Morse Fall Scale），才能根據病人的特定風險因素（如視力、步態、用藥）制訂客製化的防範措施。其他選項屬於介入措施，必須建立在準確的評估之後。
The nursing process always begins with assessment. A comprehensive fall risk assessment (such as the Morse Fall Scale) must be performed first so that individualized preventive measures can be developed based on the client's specific risk factors (vision, gait, medications, etc.). The other options are interventions that must be built upon an accurate assessment.
✦ 台美臨床差異
台灣醫院評鑑非常重視跌倒評估表的完成率與定期複評，此概念與美國一致。