— 安全與感染控制 · EASY · MCQ —
護理師評估一位病人的跌倒風險，哪一位病人最優先需要介入跌倒預防措施？
A nurse is assessing a client for fall risks. Which client has the highest priority for fall prevention interventions?
- AA 50-year-old recovering from an appendectomy50歲，正從闌尾切除術中恢復
- BA 40-year-old with a localized infection40歲，患有局部感染
- CA 25-year-old with a sprained ankle25歲，患有踝關節扭傷
- DAn 80-year-old taking a prescribed diuretic✓ 正解80歲，服用處方利尿劑
— Explanation · 中文詳解 —
跌倒風險評估的核心在於識別病人是否具備多重危險因子（intrinsic and extrinsic factors）。80 歲長者因年齡增長伴隨肌肉萎縮與平衡能力下降，且利尿劑（diuretic）的使用常導致姿勢性低血壓（orthostatic hypotension）與頻尿，增加了夜間或如廁時的跌倒風險。
An 80-year-old client taking a diuretic has the highest fall risk due to the combined effects of advanced age-related balance issues and medication-induced orthostatic hypotension or frequent urination. These intrinsic and extrinsic factors significantly increase the likelihood of falls, especially during nighttime bathroom trips.