— 健康促進與維護 · HARD · MCQ —
一位 70 歲客戶接受健康促進評估。下列哪項發現最令護理師擔心？
A 70-year-old client is being evaluated for health promotion. Which assessment finding is most concerning to the nurse?
- AThe client reports sleeping 7 hours a night客戶報告每晚睡 7 小時
- BThe client eats three small meals a day客戶每天吃三頓小餐
- CThe client has had two falls in the past 6 months✓ 正解客戶在過去 6 個月內跌倒兩次
- DThe client reads books to stay mentally active客戶透過閱讀書籍來保持大腦活躍
— Explanation · 中文詳解 —
對於 70 歲老年人，半年內跌倒兩次是極高的跌倒風險指標（Fall risk assessment）。這暗示可能有步態不穩、視力問題、環境風險或藥物副作用。A、D、B 皆為健康的老化行為，唯有 B 是急需介入的紅旗跡象。
Experiencing two falls within six months is a significant red flag indicating a high risk for injury and potential underlying issues such as gait instability, vision problems, or medication side effects. In contrast, adequate sleep, frequent small meals, and mental stimulation are generally considered healthy aging behaviors.
✦ 台美臨床差異
美台皆將「跌倒評估」列為老年護理核心評估項目，處理方式均包含多專業介入。