— 照護管理 · MEDIUM · MCQ —
護理師照顧一位意識混亂的高齡病人。下列哪項是預防跌倒且限制性最少的替代方案？
A nurse is caring for an older adult patient who is confused. What is the least restrictive alternative for preventing falls?
- APhysical vest restraint使用身體束衣約束
- BApplying four-point side rails安裝四邊床欄
- CPlacing the bed in the lowest position with a floor mat✓ 正解將病床調至最低位置並放置地板墊
- DSedating the patient to keep them calm鎮靜病人以保持安靜
— Explanation · 中文詳解 —
護理倫理要求使用「最少限制性原則」（Least Restrictive Environment）。降低床位與放置地墊能預防傷害且不限制病人活動；反觀約束衣、鎮靜劑或全上床欄均屬侵入性限制，應在所有替代方案無效後才考慮。
Delirium tremens is characterized by severe autonomic hyperactivity, including hypertension and tachycardia, along with disorientation and agitation. Visual or tactile hallucinations and generalized tonic-clonic seizures are also hallmark symptoms indicating progression to this critical stage of alcohol withdrawal.
✦ 台美臨床差異
美國對於身體約束有非常嚴謹的文獻紀錄要求；台灣臨床對於約束使用較為寬鬆，需特別留意護理紀錄之完整性以規避法律責任。