# 一名老年個案在服用降血壓藥物後，站立時感到頭暈。護理師應實施哪項介入措施？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397159&lang=zh-tw  
> language: zh-TW  
> subject: Accident/Error/Injury Prevention  
> category: SIPC

## 題目

一名老年個案在服用降血壓藥物後，站立時感到頭暈。護理師應實施哪項介入措施？

## 選項

1. 將床保持在最高位置以便於轉移。
2. 鼓勵個案快速站立以恢復循環。
3. 限制當天剩餘時間的液體攝取。
4. 協助個案緩慢起身，並在走動前使用叫人鈴。 **✔ 正確答案**

**正確答案: 4**

## 解析

姿勢改變時頭暈暗示姿勢性低血壓，並增加跌倒風險。護理師應協助緩慢改變姿勢，並確保走動前有協助可用。高床、快速站立和限制液體會增加風險。

## 深入解析

臨床判斷
使用個案線索、時間點、檢驗數據和安全風險，選擇最符合姿勢性低血壓跌倒風險的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX 考題獎勵基於線索的優先思考，而非單獨的記憶。

## 臨床情境

臨床實務指引
對於姿勢性低血壓跌倒風險，將完整的線索模式與個案當前的穩定性、醫囑數據和預期的護理範圍進行比較。

注意
當完整情境改變了優先順序或安全性時，不要僅根據單一線索選擇行動。

## 重要概念

- **姿勢性低血壓** — 移動到直立姿勢時發生的血壓下降。
- **跌倒預防** — 降低跌倒或受傷風險的介入措施。
- **叫人鈴** — 個案用來請求工作人員協助的裝置。

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