— 安全與感染控制 · MEDIUM · SATA —
護理師評估病人的跌倒風險，下列哪些屬於高優先級指標？（選所有適合的）
A nurse is assessing a client for fall risks. Which factors are considered high-priority indicators for fall prevention? (Select all that apply.)
- AHistory of recent falls✓ 正解近期跌倒史
- BUse of antihypertensive medications✓ 正解使用降血壓藥物
- CClient age over 65✓ 正解客戶年齡超過 65 歲
- DImpaired visual acuity✓ 正解視力受損
- EAbility to ambulate independently without a cane無需拐杖即可獨立行走的能力
— Explanation · 中文詳解 —
跌倒風險評估（Fall Risk Assessment）是護理師預防住院病人意外的重要職責。根據 Morse Fall Scale 等標準，跌倒史是預測再次跌倒的最強因子。藥物（如降血壓藥、鎮靜劑）會影響平衡感；高齡與視覺障礙則是生理退化因素。護理師應針對這些指標高分群採取強化預防措施（如床邊警報、陪伴）。
A history of falls is the strongest predictor of future falls, making it a high-priority assessment factor alongside advanced age, impaired vision, and the use of antihypertensive medications which may cause orthostatic hypotension. These factors significantly increase instability and risk for injury, requiring targeted prevention strategies.