護理師評估病人的跌倒風險時，應包含哪些因素？（選所有適合的）

跌倒（falls）是住院病人常見的意外事件，可能導致嚴重傷害，甚至危及生命。護理師需要系統性地評估病人的跌倒風險（risk of falls），並採取相應的預防措施。 正確選項分析： A. 藥物史（Medication history）：某些藥物，特別是鎮靜劑（sedatives）、安眠藥（hypnotics）、抗憂鬱藥（antidepressants）、降血壓藥（antihypertensives）和利尿劑（diuretics），可能引起頭暈、嗜睡、姿態性低血壓或排尿頻繁，增加跌倒風險。 B. 視力障礙（Visual impairment）：視力不佳會影響病人對環境的感知，增加絆倒或撞擊的風險，尤其是在光線不足或對環境不熟悉時。 C. 過去跌倒史（History of previous falls）：有過跌倒史的病人，其再次跌倒的風險顯著升高，這是最可靠的預測因子之一。 D. 使用輔助裝置（Use of assistive devices）：病人若需使用助行器、拐杖或輪椅，表示其行動能力或平衡感可能受損，跌倒風險相對較高。 錯誤選項分析： E. 高蛋白飲食（High protein diet）：高蛋白飲食通常被認為對健康有益，有助於組織修復和維持肌肉量，與跌倒風險沒有直接關聯，反而可能間接有益於維持肌力。 臨床思路：跌倒預防是病人安全（Patient safety）的核心。護理師應全面評估影響病人安全移動的因素。ABC 原則中的 A（Airway）對應到病人意識狀態（若因藥物影響意識不清），B（Breathing）對應到呼吸順暢（若因疾病影響呼吸而頭暈），C（Circulation）對應到血壓穩定（姿勢性低血壓）。

Falls are a common incident in hospitalized patients and can cause severe injury or even death. The nurse must systematically assess the patient's risk of falls and implement appropriate prevention measures. Analysis of correct options: A. Medication history: Certain drugs — especially sedatives, hypnotics, antidepressants, antihypertensives, and diuretics — can cause dizziness, drowsiness, orthostatic hypotension, or urinary frequency, increasing fall risk. B. Visual impairment: Poor vision impairs perception of the environment and increases the risk of tripping or collision, especially in low-light or unfamiliar surroundings. C. History of previous falls: Patients with a previous fall are at significantly higher risk of falling again; this is one of the most reliable predictors. D. Use of assistive devices: Patients who require walkers, canes, or wheelchairs have impaired mobility or balance, which is associated with a higher fall risk. Analysis of incorrect option: E. High protein diet: A high-protein diet is generally considered beneficial, supporting tissue repair and maintenance of muscle mass; it is not directly associated with fall risk and may indirectly help maintain muscle strength. Clinical reasoning: Fall prevention is central to patient safety. The nurse should comprehensively assess factors affecting safe mobility. In ABC terms, A (Airway) corresponds to level of consciousness (if medications impair alertness), B (Breathing) corresponds to airway/respiratory status (illness causing dizziness from respiratory compromise), and C (Circulation) corresponds to stable blood pressure (orthostatic hypotension).