— 基本照護與舒適 · HARD · MCQ —
病人發生跌倒，事件發生後最重要的護理行動為何？
A client is experiencing a fall. Which is the most important nursing intervention immediately following the event?
- AComplete the incident report form填寫事故報告表
- BNotify the family member immediately立即通知家屬
- CImmediately assist the client back to bed立即協助客戶回到床上
- DAssess the client for injuries before moving✓ 正解移動前先評估客戶是否有受傷
— Explanation · 中文詳解 —
跌倒後的第一優先事項是評估傷勢（特別是頭部外傷、骨折或脊椎損傷）。在未完成完整物理評估（Check for injury/vital signs）前，移動病人可能導致繼發性傷害。事件報告與家屬通知雖必要，但皆列在安全評估之後。
Assessing the client for injuries is the most critical immediate intervention to determine if movement is safe. Moving a patient without first evaluating for fractures or spinal injuries can cause further harm. Incident reports and family notifications are necessary administrative tasks but must follow the primary focus on patient safety and clinical assessment.
✦ 台美臨床差異
美國醫院有嚴格的非移動原則（No-Lift policy），需經醫師評估；台灣臨床有時家屬會要求立即搬動，護理師需堅持評估原則。