評估跌倒風險時，護理師應考量哪些因子？（選所有適合的）
When assessing for risks of falls, which factors should the nurse consider? (Select all that apply.)
- AHistory of previous falls✓ 正解既往跌倒史
- BUse of antihypertensive medications✓ 正解使用抗高血壓藥物
- CPatient's mental status✓ 正解病人的精神狀態
- DAdequate nutrition status充足的營養狀態
- EAbility to ambulate independently✓ 正解獨立行走的能力
跌倒風險評估是臨床安全照護的核心，護理師需透過多面向評估（Morse Fall Scale 等工具）識別高風險群。正確選項皆屬臨床實證中的高危險因子：過去跌倒史是再跌倒最強的預測指標；抗高血壓藥物易導致姿位性低血壓（Orthostatic Hypotension）；意識狀態混亂或認知受損會影響病人對環境安全之判斷；步態不穩則直接增加行動失控風險。營養狀態雖對整體健康重要，但非跌倒風險之獨立關鍵因子。
A history of previous falls is the strongest predictor of future falls, making it a critical assessment factor. Antihypertensive medications can cause dizziness or orthostatic hypotension, increasing fall risk. Altered mental status impairs judgment and safety awareness, while impaired ability to ambulate independently directly compromises physical stability. Adequate nutrition is generally protective rather than a primary risk factor for falls.