— 降低風險 · EASY · SATA —
護理師為高跌倒風險的病人制定護理計畫，應包含哪些措施？（選所有適合的）
A nurse is developing a plan of care for a client who is at high risk for falls. Which interventions should the nurse include? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解維持病床在最低位置
- BPlace the call bell within easy reach✓ 正解將呼叫鈴放在容易取得之處
- CApply soft physical restraints to prevent movement使用軟性身體約束以防止活動
- DEnsure the room is well-lit at night✓ 正解確保夜間房間照明充足
- EInstruct the client to call for assistance before getting up✓ 正解指示病人在起身前先尋求協助
— Explanation · 中文詳解 —
預防跌倒的核心在於環境安全與病人教育。低床位、易觸及的呼叫鈴、夜間照明及下床前呼叫輔助，均能有效降低事故發生。使用身體約束（C選項）會導致病人焦慮或掙扎，反而增加跌倒受傷程度，非預防跌倒的優先或常規手段。
To reduce fall risk, the nurse should keep the bed in the lowest position, place the call bell within easy reach, ensure the room is well-lit at night, and instruct the client to call for assistance before getting up. Physical restraints are contraindicated as they increase the risk of injury and agitation rather than preventing falls.
✦ 台美臨床差異
美國醫院極度強調防跌措施的文獻記錄與評分表落實，台灣則在環境設施如床欄與扶手配置上與國際標準接軌。