— 基本照護與舒適 · EASY · MCQ —
護理師照護一位有跌倒風險的老年病人。下列哪項環境安全措施最重要？
A nurse is caring for an elderly client at risk for falls. Which environmental safety measure is most important?
- ALeaving the bed rails down at all times始終將床欄放下
- BEnsuring the call light is within reach✓ 正解確保呼叫鈴在可觸及範圍內
- CMoving the furniture to the center of the room將家具移至房間中央
- DKeeping the room lights off for sleep為讓病人睡眠而保持房間燈光關閉
— Explanation · 中文詳解 —
跌倒預防是 NCLEX 中的核心安全議題。對於高風險老年病人，護理措施應聚焦於減少「個體需自行下床」的動機與機會。將呼叫鈴（call light）放置於病人可及範圍，能確保病人有需求時能及時尋求協助，避免因嘗試自行下床而發生跌倒。環境安全評估優先順序為：確保溝通管道暢通、環境照明充足、動線無障礙、以及依風險評估決定床欄與輔具使用。
Fall prevention in high-risk older adults focuses on minimizing the need or opportunity to get out of bed independently. Ensuring the call light is within reach allows the client to summon help, reducing the urge to self-ambulate. Adequate lighting, clear pathways, and selective use of side rails complement this priority.
✦ 台美臨床差異
在美國臨床實務中，床欄（side rails）的使用被嚴格管理，兩側床欄全升有時被視為約束（restraint），因此護理師需依據病人的 Fall Risk Assessment 進行個別化決策，並詳實記錄。