— 降低風險 · EASY · MCQ —
護理師照護有跌倒史的病人。哪項護理措施是降低受傷風險的優先考量？
A nurse is caring for a client with a history of falls. Which intervention is the priority to reduce the risk of injury?
- AEnsure the call light is within reach確保呼叫鈴在可及範圍內
- BRemind the client to call for assistance before getting up提醒個案在下床前尋求協助
- CPlace a fall risk wristband on the client在個案手腕上佩戴跌倒風險識別帶
- DKeep the bed in the lowest position✓ 正解保持病床處於最低位置
— Explanation · 中文詳解 —
在風險降低策略中，「環境安全」是護理師可以直接掌控的最核心行動。將床位降至最低位置是預防萬一跌倒時受傷程度最直接的方法。雖然 C, B, A 都是跌倒防範的一部分，但 D 屬於具體的環境介入，能最直接降低受傷風險。
Keeping the bed in the lowest position is the priority environmental intervention because it minimizes the distance and impact force if the client falls, thereby reducing injury severity. While call lights and wristbands are important components of fall prevention, they rely on client compliance or identification rather than directly mitigating physical harm during an accidental fall.
✦ 台美臨床差異
美國醫院法律責任重，對「環境安全」如床位高度、警報墊 (Bed alarm) 的執行力極強；台灣則更偏向家屬陪侍陪伴。