— 降低風險 · MEDIUM · SATA —
護理師照護一位高跌倒風險的病人時，應採取哪些措施？（選所有適合的）
Which of the following actions should the nurse take when caring for a client who is at high risk for falls? (Select all that apply.)
- AKeep the call light within the client's reach✓ 正解將呼叫鈴置於病人可及之處
- BPlace the client's bed in the lowest position✓ 正解將病床調整至最低位置
- CApply physical restraints to keep the client in bed對病人實施身體約束以使其留在床上
- DEncourage the client to use non-slip footwear✓ 正解鼓勵病人穿著防滑鞋
- EEnsure the room environment is free of clutter✓ 正解確保房間環境無雜物
— Explanation · 中文詳解 —
跌倒預防的核心在於環境安全與病人教育。呼叫鈴在手、病床維持低位、穿防滑鞋以及移除障礙物都是實證支持的預防跌倒措施。使用物理約束（C）並非跌倒預防的首選，因為其可能導致病人掙扎增加跌倒風險，且在法律與倫理上有嚴格限制，除非必要且有醫囑方可使用。
Fall prevention strategies include keeping the call light within reach, maintaining the bed in the lowest position, encouraging non-slip footwear, and ensuring a clutter-free environment. These measures promote safety and independence without restricting movement. Physical restraints are generally avoided as they can increase agitation and the risk of injury.
✦ 台美臨床差異
美國醫院有強制性跌倒風險評估工具（如 Morse Fall Scale）連結護理措施，台灣則多透過病安評估表單，執行力同樣受到高度重視。