— 安全與感染控制 · MEDIUM · MCQ —
護理師使用 Morse Fall Scale 評估病人的跌倒風險，哪項因素權重最高？
A client is being assessed for fall risk using the Morse Fall Scale. Which factor should the nurse identify as increasing the risk the most?
- AUse of assistive devices使用輔助器具
- BHistory of falling within the last 3 months✓ 正解過去三個月內有跌倒史
- CPresence of an intravenous line存在靜脈輸液線路
- DAge over 65 years年齡超過65歲
— Explanation · 中文詳解 —
Morse Fall Scale 中，評估病史至關重要。過去三個月內曾有跌倒紀錄的病人，其再次跌倒機率顯著提高。其他選項如高齡、使用輔具或有管路，雖然也列入評分項目，但歷史跌倒紀錄在臨床統計預測價值上最為顯著。
A recent history of falling within the past three months is the strongest predictor of future falls and carries the highest weight on the Morse Fall Scale. While age, assistive device use, and IV lines contribute to risk, they are less significant factors than a documented history of falls.
✦ 台美臨床差異
台灣醫院評鑑對跌倒風險管理嚴格，護理師需於每班評估並執行預防措施，美國則多由電子病歷自動化警示。