— 照護管理 · EASY · MCQ —
護理師為有跌倒史的病人規劃照護計畫，下列哪項優先？
A nurse is planning care for a client with a history of falls. Which intervention is the priority?
- AEncouraging the client to walk without assistance鼓勵個案在不協助下行走
- BApplying a physical restraint to prevent movement使用身體約束以防止移動
- CPlacing the client in a room near the nurse's station✓ 正解將個案安置在護理站附近的房間
- DAdministering a sedative to keep the client quiet給予鎮靜劑以保持個案安靜
— Explanation · 中文詳解 —
跌倒高風險病人的護理規劃，首重「環境監測」。將有跌倒史的病人安置於護理站旁（near the nurse's station），能讓護理師隨時觀察病人狀態，並在病人下床或需要協助時迅速介入。其他措施如約束（restraints）或鎮靜（sedatives）具有侵入性或副作用，不應作為預防跌倒的首選。鼓勵病人不加協助行走則違反安全原則，必須確保病人有協助下才能活動。
For high-fall-risk clients, environmental monitoring is the priority. Placing the client near the nurses' station allows continuous observation and prompt intervention. Other measures such as restraints or sedatives carry invasive risks and side effects and should not be first-line prevention. Encouraging unassisted ambulation violates safety principles—activity must be supervised.