— 基本照護與舒適 · MEDIUM · MCQ —
一位意識混亂且高跌倒風險的老年病人。護理師首要行動是什麼？
A nurse is caring for an older adult who is confused and at risk for falls. What is the best initial nursing action?
- AAsk family members to stay with the client要求家屬留在病人身邊
- BMove the client to a room near the nurses' station✓ 正解將病人移至護理站附近的房間
- CApply soft physical restraints使用軟質身體約束
- DAdminister an anti-anxiety medication給予抗焦慮藥物
— Explanation · 中文詳解 —
對於意識混亂且高跌倒風險的老年病人，首要目標是「提高觀察頻率」。將病人安置於護理站附近（Close to nurses' station）能確保護理師隨時觀察其動態，這是最安全且非侵入性的護理處置。約束與藥物屬於最後手段，在未排除非侵入性措施前不應使用。家屬陪伴雖有幫助，但不能取代專業護理人員的觀察責任。
Moving the confused client near the nurses' station allows for direct observation, which is the safest initial intervention to prevent falls. Restraints and medications increase fall risk or are reserved for last resorts, while family support does not replace professional monitoring.