— 照護管理 · EASY · MCQ —
護理師準備協助有跌倒病史的病人如廁，首要的介入措施為何？
A nurse is preparing to transfer a client with a history of falls to the bathroom. What is the priority intervention?
- AEnsure the call light is within reach確保呼叫鈴在可觸及範圍內
- BRequest assistance from a second staff member請求第二位員工協助
- CApply a gait belt around the client's waist在病人腰部繫上步態束帶
- DAssess the client's gait and balance before moving✓ 正解移動前評估病人的步態與平衡能力
— Explanation · 中文詳解 —
在執行任何轉位活動前，護理師的首要步驟是評估病人的生理狀況（評估步態與平衡能力），以確定是否需要輔助工具或額外人力。這屬於護理評估過程的關鍵，若未先評估而直接嘗試，風險極大。評估後的決策才能決定使用束帶或需要人力協助。
Before transferring a client with a history of falls, the nurse must first assess the client's gait and balance to determine the appropriate level of assistance required. This initial assessment ensures safety by identifying whether additional help or assistive devices, such as a gait belt, are necessary. Skipping this step to directly apply equipment or request help without evaluation increases the risk of injury.
✦ 台美臨床差異
兩地均強調跌倒預防；美國臨床常使用跌倒預防問卷（如 Morse Fall Scale）系統化評估，台灣則依據醫院評鑑準則進行防跌評估。