— 安全與感染控制 · MEDIUM · SATA —
護理師評估病人的跌倒風險，下列哪些因素會增加跌倒機率？（選所有適合的）
A nurse is assessing a client's risk for falls. Which factors increase the risk of falling? (Select all that apply.)
- AHistory of a previous fall✓ 正解曾有跌倒史
- BAge 65 years or older✓ 正解年齡 65 歲或以上
- CUse of antihypertensive medications✓ 正解使用抗高血壓藥物
- DIndependent mobility具備獨立行動能力
- EVisual impairment✓ 正解視覺障礙
— Explanation · 中文詳解 —
跌倒風險評估是 NCLEX 的重點，護理師需識別生理、藥物與環境風險。跌倒病史是未來跌倒最強的預測因子。高齡會導致反應變慢與肌力下降，降壓藥物可能引起姿勢性低血壓（orthostatic hypotension），而視覺障礙則會影響平衡與路徑判斷。護理師應針對這些因子制定預防計畫，如防滑襪、床欄使用及藥物監測。相反地，獨立移動能力通常顯示較好的功能狀態，除非伴隨步態不穩。
A history of prior falls is the strongest predictor of future incidents. Advanced age often results in decreased muscle strength and balance, while antihypertensive medications can cause orthostatic hypotension. Additionally, visual impairment hinders the ability to identify environmental hazards, all of which significantly increase fall risk.