— 照護管理 · EASY · MCQ —
護理師為一位有跌倒病史的病患制定護理計畫，下列哪項措施應列為優先？
A nurse is developing a plan of care for a client with a history of falls. Which intervention should the nurse prioritize?
- AKeep the call light within the client's reach✓ 正解將呼叫鈴置於病人可及之處
- BAdminister sedative medications at bedtime睡前給予鎮靜藥物
- CApply physical restraints to prevent movement應用身體約束以防止移動
- DEncourage the client to get up independently for exercise鼓勵病人獨立起身運動
— Explanation · 中文詳解 —
跌倒預防的核心在於環境控制與即時回應。將呼叫鈴置於病人隨手可得之處，能有效預防病人因尋求協助而自行下床導致跌倒。鎮靜劑反而會增加跌倒風險；鼓勵自行運動應在有協助下進行；約束為最後手段，且容易增加病人激動與受傷風險。
Ensuring the call light is within the client’s reach is the highest priority intervention to promote safety and prevent falls by allowing immediate access to assistance. Sedatives increase confusion and fall risk, while independent mobility without assessment or the use of restraints can lead to injury or agitation. Providing timely support for toileting and movement needs through accessible communication tools is the most effective strategy for fall prevention.
✦ 台美臨床差異
美國醫院對跌倒防護有嚴格的評分系統與床邊警示規範；台灣亦有相關規範，但常需仰賴家屬共同監督。