— 基本照護與舒適 · MEDIUM · SATA —
護理師為有反覆跌倒病史的病人制定護理計畫。應包含哪些措施？（選所有適合的）
A nurse is creating a plan of care for a client with a history of recurrent falls. Which nursing interventions should be included? (Select all that apply.)
- AKeep the call light within reach at all times✓ 正解隨時將呼叫鈴置於病人可及之處
- BPlace the client in a room far from the nurses' station將病人安置在遠離護理站的房間
- CApply restraints to keep the client in bed使用約束帶使病人留在床上
- DEnsure the floor is free of clutter✓ 正解確保地板無雜物
- EOrient the client to the room environment✓ 正解引導病人熟悉房間環境
— Explanation · 中文詳解 —
跌倒防護計畫應以環境改造、病人教育與通訊便利為三大主軸。確保求救鈴（Call light）隨手可得是病人發生緊急狀況時的第一防線。環境應保持淨空，移除障礙物以減少絆倒風險。同時，應協助病人熟悉環境，特別是床邊設施與廁所位置。約束病人僅能在極少數臨床必要下使用，且需嚴格遵循醫師醫囑，不作為常規防跌手段。
Fall prevention strategies include keeping the call light within easy reach to ensure timely assistance and removing clutter from the floor to eliminate trip hazards. Additionally, orienting the client to the room environment helps reduce confusion and promotes safety.