— 降低風險 · EASY · SATA —
病人被診斷為跌倒高風險。哪些護理措施適合用來降低風險？（選所有適合的）
A client is diagnosed with a high risk for falling. Which nursing interventions are appropriate to reduce this risk? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床降至最低位置
- BEnsure the call light is within reach✓ 正解確保呼叫鈴在可及範圍內
- CKeep all four side rails in the upright position將四邊床欄全部拉起
- DProvide non-skid footwear✓ 正解提供防滑鞋
- EClear the floor of clutter and obstacles✓ 正解清除地板上的雜物與障礙物
— Explanation · 中文詳解 —
跌倒預防的基本措施包括：病床高度降至最低（A）、呼叫鈴放在手邊（B）、提供防滑鞋（D）以及清除地板障礙物（E）。C 選項錯誤，將四個床欄全部拉起在美國法律中被視為非法約束（False imprisonment），且可能導致病人翻越床欄造成更嚴重的受傷。
Basic measures for fall prevention include lowering the bed to the lowest position (A), keeping the call light within reach (B), providing non-skid footwear (D), and clearing the floor of obstacles (E). Option C is incorrect: raising all four side rails is considered false imprisonment under U.S. law and can result in more severe injury if the client tries to climb over the rails.
✦ 台美臨床差異
美國對「四邊床欄」的約束定義極嚴；台灣臨床實務中，對於高風險病人拉起四邊床欄較為普遍，但仍應注意病人安全與法規趨勢。