— 照護管理 · MEDIUM · SATA —
護理師針對跌倒高風險病人應採取哪些措施？（選所有適合的）
Which of the following actions by a nurse demonstrates appropriate management of a client with a history of falls? (Select all that apply.)
- AKeep the call light within the client's reach✓ 正解將呼叫鈴放在病人可觸及之處
- 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
- CEnsure the bed is in the lowest position✓ 正解確保病床處於最低位置
- DOrient the client to the room upon admission✓ 正解入院時向病人介紹病房環境
- EInstruct the client to call for assistance before getting up✓ 正解指導病人起身前先請求協助
— Explanation · 中文詳解 —
針對跌倒高風險病人的照護，需落實多層次的防範措施。首先，呼叫鈴必須在手邊，確保病人需要協助時能及時通知。其次，將病床調至最低位置，降低跌倒時的衝擊。入室時進行環境導向（orientation），讓病人熟悉環境以減少混亂。最重要的是教育病人，在下床前必須呼叫協助。將病人安置於遠離護理站的房間會增加監測難度，不利於安全防護。
Appropriate fall prevention includes keeping the call light within reach, ensuring the bed is in the lowest position, orienting the client to the room, and instructing them to call for assistance before getting up. Placing the client far from the nurses' station is inappropriate as it reduces the frequency of observation and increases safety risks.