— 安全與感染控制 · EASY · MCQ —
護理師識別出一位高齡病人的跌倒風險。跌倒預防計畫中最合適的第一步措施為何？
A nurse identifies a risk for falls in an elderly client. Which intervention is the most appropriate first step in a fall prevention program?
- APerform a standardized fall risk assessment✓ 正解執行標準化的跌倒風險評估
- BInstruct the client to call for assistance指導病人呼叫協助
- CPlace the client in a room near the nursing station將病人安置在護理站附近的房間
- DApply physical restraints使用身體約束
— Explanation · 中文詳解 —
護理程序（Nursing Process）的第一步是評估（Assessment）。在預防跌倒計畫中，護理師必須先使用客觀的工具進行跌倒風險評估（如 Morse Fall Scale），這能幫助護理師量化病人的風險水平，進而決定是否需要採取床欄、防滑襪或更嚴密的監控。在未評估前直接採取限制措施是不符合護理規範的。
The first step in a fall prevention program is to perform a standardized fall risk assessment. This evaluation establishes a baseline of the client's risk level, allowing the nurse to select appropriate, evidence-based interventions rather than relying on assumptions or restrictive measures.