# 一名夜間混亂的高齡個案反覆嘗試不經協助下床。最適當的護理措施為何？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393729&lang=zh-tw  
> language: zh-TW  
> subject: Accident/Error/Injury Prevention  
> category: SIPC

## 題目

一名夜間混亂的高齡個案反覆嘗試不經協助下床。最適當的護理措施為何？

## 選項

1. 將床降至最低、啟動床警報，並安排定時如廁。 **✔ 正確答案**
2. 使用腕部約束讓個案不能起身。
3. 升起所有床欄以防止移動。
4. 把燈全關掉讓個案睡久一點。

**正確答案: 1**

## 解析

跌倒預防應先使用最低限制安全措施，包括低床、警報、頻繁巡視與如廁安排。約束與全部床欄可能增加傷害風險，且需嚴格條件。黑暗可能加重定向障礙與跌倒風險。

## 深入解析

臨床判斷
在保留活動能力的同時，以最低限制措施降低跌倒風險。

記憶重點
低床、警報、如廁、照明、巡視先於約束。

## 臨床情境

實務指引
跌倒預防計畫結合環境安全、如廁、警報、可見度、移動支持與可逆原因再評估。

注意
只有在較低限制措施失敗且符合政策條件時才使用約束。

## 重要概念

- **跌倒預防** — 降低意外跌倒與相關傷害風險的措施。
- **最低限制** — 在盡可能保留自由的同時保護個案的安全方式。
- **床警報** — 高風險個案嘗試離床時通知工作人員的裝置。

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