— 健康促進與維護 · MEDIUM · MCQ —
護理師照顧一位有跌倒風險的高齡病人，下列哪項護理措施是護理計畫中最高優先級的？
A nurse is caring for an older adult client who is at risk for falls. Which intervention is the highest priority to include in the plan of care?
- AApply a vest restraint at night夜間使用背心式約束帶
- BEncourage the client to walk with a cane鼓勵病人使用柺杖行走
- CPlace the client in a room near the nursing station將病人安置在護理站附近的房間
- DEnsure the call light is within reach✓ 正解確保呼叫鈴在病人觸手可及之處
— Explanation · 中文詳解 —
跌倒預防的核心在於環境安全與即時協助。確保呼叫鈴在伸手可及範圍內，能讓病人需求被即時滿足，減少因無助而自行下床產生的跌倒風險。A 為侵入性限制，應儘量避免；C 是輔助措施，但非首要安全預防；D 有助監控，但無法取代呼叫鈴機制。
Ensuring the call light is within the client's reach is the highest priority to facilitate immediate assistance and prevent unsupervised attempts to ambulate. Restraints are a last resort, and while room placement aids monitoring, it does not replace the client's ability to summon help when needed.
✦ 台美臨床差異
美國對約束使用有非常嚴格的法律規範（JCAHO），台灣醫院在約束執行上依賴醫囑，但在實務上兩地皆強調儘量減少約束。