— 降低風險 · EASY · SATA —
為了預防有姿位性低血壓病史的老年病人跌倒，護理師應採取哪些措施？（選所有適合的）
Which of the following actions should the nurse take to prevent falls in an elderly client with a history of orthostatic hypotension? (Select all that apply.)
- AInstruct the client to get up slowly from a sitting or lying position✓ 正解指導病患從坐著或躺著姿勢時緩慢起身
- BEncourage the client to drink more fluids to maintain blood volume鼓勵病患多喝水以維持血容量
- CAdvise the client to dangle their legs at the bedside before standing✓ 正解建議病患在站立前將腿懸垂於床緣
- DApply compression stockings as prescribed✓ 正解依醫囑穿戴彈性襪
- ELimit physical activity to bed rest only限制身體活動僅限卧床休息
— Explanation · 中文詳解 —
姿位性低血壓防治重點在於改變姿勢時的緩衝與血管收縮輔助。應教導緩慢起身、床邊垂足（Dangling）以適應血壓變化，穿著彈性襪可減少血液堆積於下肢。鼓勵補水需視病人心臟與腎功能而定，非預防跌倒的首選。E 選項完全錯誤，過度臥床會導致肌力流失，反而增加跌倒風險。
To prevent falls in clients with orthostatic hypotension, the nurse should instruct the client to rise slowly, dangle legs at the bedside before standing, and use compression stockings to reduce venous pooling. These measures help stabilize blood pressure during position changes, whereas bed rest increases fall risk due to muscle weakness.
✦ 台美臨床差異
在美國，評估與預防跌倒（Fall Risk Assessment）是非常正式的系統，台灣則多整合在病房安全管理守則中。