— 降低風險 · EASY · SATA —
護理師照護一位有跌倒風險的病人，下列哪些照護計畫應包含其中？（選所有適合的）
A nurse is caring for a client who is at risk for falls. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
- AKeep the call light within reach✓ 正解將呼叫鈴置於患者可及之處
- BPlace the bed in the lowest position✓ 正解將病床調整至最低位置
- CEncourage the client to get up independently鼓勵患者獨立下床活動
- DEnsure the floor is free of clutter✓ 正解確保地面無雜物
- EInstruct the client to wear non-slip footwear✓ 正解指導患者穿著防滑鞋
— Explanation · 中文詳解 —
跌倒預防（Fall prevention）是住院照護的核心。策略包括：確保呼叫鈴（Call light）在病人伸手可及處、將床位調整至最低位置（Lowest position）、保持地面整潔無雜物、指導病人穿著止滑鞋具。此外，針對高風險病人，護理師應提供頻繁的巡視（Rounding），而非鼓勵病人獨自下床，除非已評估其活動能力安全無虞。
To prevent falls, the nurse should keep the call light within reach, place the bed in the lowest position, ensure the floor is free of clutter, and instruct the client to wear non-slip footwear. Encouraging independent movement without assessment increases fall risk and is not an appropriate intervention for a client at risk.