— 降低風險 · EASY · SATA —
護理師評估高齡病人的跌倒風險因子，應包含哪些項目？（選所有適合的）
A nurse is identifying fall risk factors for an elderly client. Which factors should be included in the assessment? (Select all that apply.)
- AHistory of recent falls✓ 正解近期跌倒史
- BUse of antihypertensive medications✓ 正解使用抗高血壓藥物
- CImpaired visual acuity✓ 正解視力受損
- DAdequate lighting in the room室內照明充足
- EPresence of orthostatic hypotension✓ 正解存在姿勢性低血壓
— Explanation · 中文詳解 —
跌倒風險評估應全面考慮生理、藥物與環境因素。過去跌倒史是未來跌倒最強的預測因子。降血壓藥物易致姿態性低血壓；視力減退影響環境判斷；姿勢性低血壓導致起身頭暈。充足照明則為預防措施而非風險因子。護理師應利用標準化的評估量表（如 Morse Fall Scale）來系統性評估這些風險因子，並制定預防計畫。
A history of recent falls is the strongest predictor of future falls and must be assessed. Risk factors include antihypertensive use, which can cause blood pressure fluctuations, impaired visual acuity affecting spatial awareness, and orthostatic hypotension leading to dizziness. Adequate lighting is a preventive environmental measure rather than a risk factor.