護理師為高跌倒風險病人規劃護理計畫，應包含哪些措施？（選所有適合的）
A nurse is planning care for a client who is at high risk for falls. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AKeep the call light within reach at all times✓ 正解隨時將呼叫鈴放在病人可觸及之處
- BApply physical restraints to keep the client in bed對病人實施身體約束以使其留在床上
- CPlace the client in a room near the nurses' station✓ 正解將病人安置於護理站附近的房間
- DMaintain the bed in the lowest position✓ 正解維持病床處於最低位置
- EEncourage the client to wear non-slip socks✓ 正解鼓勵病人穿著防滑襪
跌倒預防措施包含環境管理與輔助，如保持呼叫鈴易取、低位床、防滑襪，及將高風險病人安排在護理站旁以便隨時觀察。選項 B（身體約束）為最後手段，僅在評估病人嚴重混亂且危及生命時使用，非預防跌倒的常规介入。
Fall prevention measures include environmental management and assistive aids, such as keeping the call light within reach, maintaining the bed in the lowest position, providing non-slip socks, and placing high-risk clients near the nurses' station for close observation. Option B (physical restraints) is a last resort, used only when the client is severely confused and life is endangered; it is not a routine fall-prevention intervention.
美國醫院重視 Fall Risk Assessment Tool 的評分與記錄；台灣醫院同樣重視防跌，但常強調家屬陪伴參與的衛教。