護理師協助一位活動力受限的病人下床。病人表示：「我覺得頭暈。」護理師的首要行動為何？
A nurse is assisting a client with limited mobility to get out of bed. The client states, 'I feel dizzy.' Which action is the priority for the nurse?
- ACheck the client's blood pressure immediately立即測量病人的血壓
- BCall for assistance from another staff member呼叫其他人員協助
- CAssist the client to sit back down on the bed✓ 正解協助病人坐回床上
- DInstruct the client to take deep breaths指導病人深呼吸
當病人從臥姿轉換到坐姿或站姿時，血液會因重力作用向下肢聚集，可能導致回流至心臟的血液量暫時減少，進而引起血壓下降，產生頭暈（姿態性低血壓，Orthostatic Hypotension）的感覺。這種情況在活動力受限的病人尤其常見。 在病人表達頭暈時，護理師的首要任務是立即採取措施防止跌倒與潛在傷害，這符合「安全優先」原則。選項 C（協助病人坐回床上）是立即且最安全的反應，能快速增加回流至心臟的血量，緩解頭暈症狀，並預防病人因跌倒而受傷。 選項 D（深呼吸）可能對某些情況的頭暈有幫助，但無法立即解決體位改變導致的血壓變化。選項 B（呼叫協助）雖然是安全措施的一部分，但應在確保病人當下安全後再進行。選項 A（立即測量血壓）是重要的評估步驟，但病人當下的安全（預防跌倒）應優先於評估。
The client is likely experiencing orthostatic hypotension, where gravity causes blood to pool in the lower extremities upon standing, leading to decreased venous return and transient dizziness. The nurse’s priority is to ensure safety by preventing falls, which is best achieved by immediately assisting the client to sit back down on the bed. This position helps restore cerebral perfusion and alleviates symptoms more effectively than assessment or other interventions.