護理師審視高跌倒風險病人的安全規範，應採取哪些措施？（選所有適合的）
A nurse is reviewing safety protocols for a client at high risk for falls. Which interventions should the nurse implement? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- BEnsure the call light is within easy reach✓ 正解確保呼叫鈴在容易觸及之處
- CKeep the environment clutter-free✓ 正解保持環境無雜物
- DApply physical restraints to keep the client in bed使用身體約束帶將病人固定在床上
- EEncourage the client to use non-slip footwear✓ 正解鼓勵病人穿著防滑鞋
預防跌倒應採取以病人安全為中心且尊重其自主性的措施。保持低床位、呼叫鈴在側、環境整潔及穿著止滑鞋均是低侵入性且有效的措施。使用身體約束（Physical restraints）是最後手段，僅在評估病人的安全性極度危急且其他方法無效時才可考慮，不屬於常規的跌倒預防措施。
Fall prevention should employ measures that center on patient safety while respecting autonomy. Keeping the bed in the lowest position, placing the call light within reach, maintaining a clutter-free environment, and using non-slip footwear are all low-invasiveness, effective measures. Physical restraints are a last resort and should be considered only when the client's safety is severely jeopardized and other methods have proven ineffective; they are not part of routine fall prevention.
美國對於約束的使用有嚴格法律規範與紀錄要求（Restraint documentation）；台灣實務中約束使用頻率較高。