— 照護管理 · MEDIUM · SATA —
護理師照顧一位意識混亂且有高跌倒風險的病人，下列哪些行動是適當的？（選所有適合的）
A nurse is caring for a client who is confused and at high risk for falls. Which actions are appropriate for the nurse to take? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- BPlace the client in a room near the nurses' station✓ 正解將病人安置在護理站附近的房間
- CApply four-point physical restraints immediately立即施加四點身體約束
- DEnsure the call light is within the client's reach✓ 正解確保呼叫鈴在病人觸手可及之處
- EApply a bed alarm to alert staff if the client attempts to get up✓ 正解安裝床邊警報器，以便在病人試圖起身時通知工作人員
— Explanation · 中文詳解 —
預防跌倒應優先使用非侵入性措施。降低床位、安置於護理站旁利於觀察、確保呼叫鈴可及、使用床邊警報器（Bed alarm）皆為有效策略。身體約束（Restraints）為最後手段，需醫師醫囑且定期評估，不可未經評估即刻施加。
To prevent falls in a confused client, nurses should implement non-invasive safety measures such as keeping the bed in the lowest position, placing the client near the nurses' station for frequent observation, ensuring the call light is within reach, and using bed alarms. Physical restraints are a last resort requiring a provider's order and should not be applied immediately without assessment.
✦ 台美臨床差異
美台皆強調預防勝於約束。美國對約束的法律文件要求極度嚴格，台灣臨床則在照服員執行時常需加強防跌教育。