— 照護管理 · MEDIUM · MCQ —
護理師照顧有跌倒史的病人，哪項介入最能預防跌倒？
A nurse is managing a client with a history of falls. What is the most effective nursing intervention to prevent falls?
- AKeeping all four side rails raised at all times始終保持四邊床欄升起
- BPlacing the client in a room far from the nursing station將病人安置在遠離護理站的房間
- CAssessing the client's fall risk and implementing a targeted prevention plan✓ 正解評估病人的跌倒風險並實施針對性的預防計畫
- DApplying physical restraints to the client's bed對病人病床施加物理約束
— Explanation · 中文詳解 —
預防跌倒的黃金原則是「評估與個人化計畫」（如 Morse Fall Scale）。約束與拉起床欄皆非首選，甚至可能增加病人試圖爬出造成的危險。放置於護理站附近（Close observation）才是正確做法。
The most effective intervention is to assess the client's fall risk using evidence-based tools like the Morse Fall Scale and implement a targeted prevention plan. Side rails and physical restraints are not first-line strategies as they may be considered restraints and can increase injury risk. Additionally, placing the client near the nursing station facilitates closer observation rather than isolating them.
✦ 台美臨床差異
美國非常限制使用約束；台灣臨床對於約束使用率普遍較高，但也在逐步推廣「無約束」照顧。