— 降低風險 · MEDIUM · MCQ —
護理師照護一位有失智症且高跌倒風險的病人，哪項護理行動最有效？
A nurse is caring for a client with dementia who is at high risk for falls. Which nursing action is most effective?
- AKeep the bed in the highest position將病床保持在最高位置
- BFrequently assess the client's needs and provide orientation✓ 正解經常評估客戶需求並提供定向引導
- CApply physical restraints實施身體約束
- DEnsure the client is sedated at night確保客戶夜間處於鎮靜狀態
— Explanation · 中文詳解 —
預防跌倒首重非侵入性措施。失智病人常因混亂或需求未被滿足而下床，透過頻繁評估需求、進行定向感訓練，可降低焦慮與遊走風險。約束病人易導致掙扎受傷或病情惡化；床邊過高或過度給予鎮靜劑皆不符合病人安全原則。
Preventing falls in clients with dementia prioritizes non-invasive strategies, such as frequent assessment of needs and orientation techniques to reduce agitation and wandering. Physical restraints, sedation, or keeping the bed in a high position are contraindicated as they increase the risk of injury, confusion, and severe harm during a fall.
✦ 台美臨床差異
美國護理重視環境改造（Environmental modification），台灣則因照顧人力較吃緊，有時傾向過度使用保護性約束。