— 基本照護與舒適 · MEDIUM · SATA —
護理師為高跌倒風險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 planning care for a client at high risk for falls. Which 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可及範圍
- BPlace the bed in the lowest position✓ 正解將病床調至最低位置
- CAssign a sitter to be in the room 24/7指派專人 24 小時在房內看護
- DApply restraints to prevent the client from getting up使用約束帶以防止病人起身
- EEnsure the floor is clear of clutter✓ 正解確保地面無雜物堆放
— Explanation · 中文詳解 —
跌倒預防的核心在於維持環境安全與輔助設施可近性。呼叫鈴在側、床降至最低、淨空地板皆為標準預防措施。約束（restraints）為最後手段，須有嚴格醫囑與評估，不能作為常規防跌措施；24 小時坐檯（sitter）則需視資源與病人意識狀況決定，非所有高風險者皆需。
Fall prevention strategies prioritize environmental safety and accessibility, such as keeping the call light within reach, maintaining the bed in the lowest position, and ensuring floors are free of clutter. Restraints are not routine measures due to risks of agitation and injury, and sitters are reserved for specific cases involving confusion or impulsivity.
✦ 台美臨床差異
美國醫院極度強調防跌措施的紀錄與護理師的 accountability；台灣則傾向於給予防跌手環或警示貼紙。