— 降低風險 · MEDIUM · SATA —
護理師照護一位有中風史的病人。應實施哪些安全措施以預防跌倒？（選所有適合的）
A nurse is caring for a client with a history of stroke. Which safety measures should be implemented to prevent falls? (Select all that apply.)
- AApply non-skid footwear✓ 正解穿著防滑鞋
- BEncourage independent ambulation鼓勵獨立步行
- CEnsure adequate lighting in the room✓ 正解確保室內有充足照明
- DUse a gait belt during transfers✓ 正解轉移時使用步態帶
- ELock the wheels on the bed and wheelchair✓ 正解鎖定病床和輪椅的輪子
— Explanation · 中文詳解 —
中風病人因受損大腦區域影響，常見單側肢體無力（Hemiparesis）、平衡感變差及步態不穩，跌倒是住院期間最常見的安全性事件。護理措施的核心在於消除環境風險及提供物理輔助。正確選項均為標準防跌措施：防滑鞋增加摩擦力；良好照明能讓病人清楚看見障礙物；步態帶（Gait belt）能讓護理師更穩固地支撐病人重心；鎖定輪子則確保轉移時設備不會滑動。鼓勵獨立活動需先經過物理治療師評估，不可未評估即貿然鼓勵，以免發生意外。
To prevent falls in clients with a history of stroke, nurses should implement safety measures such as providing non-skid footwear, ensuring adequate lighting, using a gait belt during transfers, and locking bed and wheelchair wheels. These interventions address common risks like hemiparesis and balance issues by eliminating environmental hazards and providing physical support.