— 降低風險 · EASY · MCQ —
護理師照護一位跌倒高風險的病人。下列哪項護理措施最能確保安全？
A nurse is caring for a client who is at high risk for falls. Which nursing intervention is most appropriate to ensure safety?
- ADim the lights to promote better sleep and relaxation調暗燈光以促進睡眠和放鬆
- BAssign a family member to supervise the patient at all times指派家屬全程監護病人
- CKeep the bed in the lowest position with wheels locked✓ 正解保持病床處於最低位置並鎖定輪子
- DApply physical restraints to keep the patient in bed使用身體約束將病人固定在床上
— Explanation · 中文詳解 —
降低跌倒風險的核心原則是預防環境障礙。將床位降至最低並鎖定輪腳是臨床跌倒預防標準作業程序。使用約束（選項 D）僅限於生命危險或極度躁動時，且需遵循嚴格法律規範；家人陪伴（選項 B）雖有幫助，但非結構性預防措施；調暗燈光（選項 A）反而增加跌倒風險。
Keeping the bed in the lowest position with wheels locked is a primary environmental intervention to reduce fall risk by minimizing the distance of a potential fall. Restraints are a last resort, dim lighting increases danger, and family supervision is not a reliable standard nursing intervention.
✦ 台美臨床差異
美國醫院極度強調防跌措施（如床鈴提醒），台灣則多採取照服員或家屬陪護模式。