— 安全與感染控制 · MEDIUM · SATA —
護理師評估一位高齡病人有跌倒風險，應採取哪些措施？（選所有適合的）
A nurse identifies a potential risk for falls in an elderly client. Which interventions should the nurse implement? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解保持病床處於最低位置
- BEnsure the call light is within reach✓ 正解確保呼叫鈴在可及範圍內
- CApply restraints to prevent the client from getting up應用約束帶以防止病人起身
- DKeep the floor free of clutter✓ 正解保持地板無雜物
- EPlace the client in a room near the nurses' station✓ 正解將病人安置在護理站附近的房間
— Explanation · 中文詳解 —
防跌措施重點在於環境優化與監測。將床位降至最低以防墜落，確保求助鈴可及，保持地面乾燥整潔。將高危險病人放置在護理站旁，方便觀察。約束（C）是最後手段，不可作為預防跌倒的常規手段，因為這可能導致病人更焦慮而跌倒。
Fall prevention strategies include keeping the bed in the lowest position, ensuring the call light is within reach, keeping the floor free of clutter, and placing the client near the nurses' station for closer monitoring. Restraints are not appropriate as they can increase agitation and confusion, potentially raising the risk of injury rather than preventing it.
✦ 台美臨床差異
美方對於「約束」規範極其嚴格，需嚴格記錄且定期重新評估；台灣亦然，但臨床上常因家屬要求而較早使用。