— 安全與感染控制 · MEDIUM · MCQ —
護理師評估病人的跌倒風險。下列哪位病人應優先執行跌倒預防計畫？
A nurse is assessing a client for fall risks. Which client has the highest priority for the implementation of fall prevention protocols?
- AA 60-year-old scheduled for elective cataract surgery一位預約進行擇期白內障手術的 60 歲患者
- BA 50-year-old with type 2 diabetes and stable blood glucose一位患有第二型糖尿病且血糖穩定的 50 歲患者
- CA 75-year-old admitted for weakness following a recent stroke✓ 正解一位因近期中風而虛弱住院的 75 歲患者
- DAn 80-year-old with a history of hypertension and stable gait一位有高血壓病史且步態穩定的 80 歲患者
— Explanation · 中文詳解 —
跌倒風險評估的核心在於識別生理機能的改變。中風（Stroke）後病人常伴隨單側肢體無力（Hemiparesis）、本體感覺受損與平衡功能障礙，這些是臨床上極高的跌倒危險因子。護理師應運用 Morse Fall Scale 等量表，優先針對急性期、活動能力受損的病人啟動預防計畫，如使用警示手環、床邊警報系統及增加協助頻率，以確保病人安全。
A client with recent stroke-related weakness faces the highest fall risk due to potential hemiparesis, impaired coordination, and balance deficits. These physiological changes significantly compromise mobility and safety, necessitating immediate implementation of fall prevention protocols compared to clients with stable conditions or elective procedures.