— 安全與感染控制 · EASY · MCQ —
護理師發現一位新入院高齡病人有潛在跌倒風險，下列哪項介入措施應優先執行？
A nurse identifies a potential fall risk in a newly admitted older adult client. Which intervention should be prioritized?
- AApply physical restraints to keep the client in bed使用身體約束將病人固定在床上
- BPlace the call light within the client's reach✓ 正解將呼叫鈴放置在病人可觸及之處
- CAssign a family member to sit with the client指派家屬陪伴病人
- DKeep all four side rails raised at all times隨時保持四邊床欄升起
— Explanation · 中文詳解 —
跌倒預防的首要策略是促進病人的安全性與自主性。將呼叫鈴放置在病人隨手可得的地方，能讓病人主動尋求協助，而非自行下床導致跌倒。身體約束需有醫囑且為最後手段，四邊床欄升起若病人試圖翻越反而增加跌倒風險，家屬陪同雖有幫助但非第一優先的護理技術介入。
Promoting client safety and autonomy is the priority in fall prevention. Placing the call light within easy reach allows the client to request assistance rather than attempting to get out of bed alone, which significantly reduces fall risk. Physical restraints are a last resort requiring a physician's order, and raising all side rails can actually increase injury risk if the client attempts to climb over them.
✦ 台美臨床差異
美台對約束的法律定義皆嚴，美國對「Least Restrictive Environment」的要求比台灣更為嚴格且頻繁稽核。