— 安全與感染控制 · EASY · SATA —
護理師為高齡病人執行跌倒預防措施。哪些處置是合適的？（選所有適合的）
A nurse is implementing fall precautions for an older adult client. Which interventions are appropriate? (Select all that apply.)
- AProvide non-skid footwear✓ 正解提供防滑鞋
- BEnsure the call light is within reach✓ 正解確保呼叫鈴在觸手可及之處
- CKeep the room well-lit during the day✓ 正解白天保持房間照明充足
- DEncourage the client to use the bathroom independently鼓勵病人獨立使用廁所
- EComplete a fall risk assessment on admission✓ 正解入院時完成跌倒風險評估
— Explanation · 中文詳解 —
跌倒預防包含：提供防滑鞋、確保呼叫鈴在手邊、維持光線充足、入院時進行跌倒評估（如 Morse Scale）。D 錯誤：高風險病人應在協助下如廁（Stay with the patient），不可鼓勵獨自前往以防意外。
Appropriate fall precautions include providing non-skid footwear, keeping call lights within reach, maintaining adequate lighting, and conducting a fall risk assessment upon admission. Encouraging high-risk clients to use the bathroom independently is unsafe and should be avoided.
✦ 台美臨床差異
美國常使用黃色手環或黃色襪子標記跌倒高風險群；台灣臨床多在床頭卡標示「防跌」標誌，處置內容基本一致。