一位處於防跌倒計畫中的病人試圖獨自下床。護理師優先採取什麼行動？

當病人處於跌倒高風險狀態（fall precautions）時，護理師的首要任務是確保其人身安全，預防跌倒事件的發生。一旦觀察到病人試圖進行危險行為，必須立即介入。 正確答案 A 是最優先的行動。當病人試圖獨自下床時，護理師應立即上前協助病人安全返回床上。這直接阻止了潛在的跌倒事件，是維護病人即時安全的關鍵措施。 錯誤選項 C（使用約束）是最後的手段，必須有醫師醫囑，且需嚴格遵循相關規定，並非首要介入措施。在病人僅是試圖下床時，立即協助回床比約束更人道且有效。錯誤選項 D（衛教）雖然重要，但應在病人安全得到保障後進行，不能取代立即的介入。錯誤選項 B（聯絡醫師）雖然可能需要，但應在確保病人當前安全後進行，不能延誤立即的介入。

When a client is on fall precautions, the nurse's primary responsibility is to ensure the client's physical safety and prevent a fall from occurring. Once unsafe behavior is observed, immediate intervention is required. The correct answer, A, is the priority action. When the client attempts to get out of bed alone, the nurse should immediately step in and safely assist the client back to bed. This directly prevents a potential fall and is the critical measure for maintaining the client's immediate safety. Incorrect option C (applying restraints) is a last resort, requires a physician's order, and must follow strict criteria; it is not the priority intervention. When the client is only attempting to get up, assisting back to bed is more humane and effective than restraints. Incorrect option D (education) is important, but it should be performed after the client's safety is secured and cannot replace immediate intervention. Incorrect option B (notifying the physician) may be necessary, but only after the client's immediate safety is ensured; it cannot delay direct intervention.

跌倒預防與介入措施在台美兩地醫療機構中都極為重視。美國對於跌倒預防有更系統化的評估工具與介入策略，如 Morse Fall Scale 等，並有嚴格的約束使用規範。台灣的護理師也執行跌倒風險評估與預防，但約束的使用可能在臨床實踐上較為彈性，不過核心的「病人安全第一」原則是相同的。