針對跌倒高風險的病人，下列哪些護理措施是合適的？（選所有適合的）
Which of the following interventions are appropriate for a client who is at high risk for falls? (Select all that apply.)
- AKeep the call light within reach✓ 正解將呼叫鈴放在觸手可及之處
- BPlace the bed in the lowest position✓ 正解將病床調整至最低位置
- CApply four-side bed rails安裝四邊床欄
- DPlace the client in a room near the nurses' station✓ 正解將個案安置在護理站附近的房間
- EEnsure the floor is free of clutter✓ 正解確保地面無雜物
預防跌倒是病房安全管理的首要任務。應採取多層次的防範措施，包括環境評估與病人監控。呼叫鈴在手邊能減少病人自行下床的衝動，低床位可減緩跌倒後的衝擊力，放置在護理站附近能確保護理師在第一時間反應，淨空環境則消除絆倒風險。四邊護欄升起通常被視為約束（restraint），若無醫療必要，反而增加病人翻越摔傷的風險。
Fall prevention is the top priority of ward safety management. Multilayered preventive measures must be taken, including environmental evaluation and patient monitoring. Keeping the call light within reach reduces the patient's urge to get out of bed independently; a low bed position reduces the impact of a fall; locating the patient near the nurses' station ensures that the nurse can respond immediately; and keeping the environment clear eliminates tripping hazards. Raising all four side rails is generally considered a form of restraint, and in the absence of medical necessity, can in fact increase the risk that the patient climbs over and falls.
在美國醫院，四邊護欄升起被嚴格定義為「身體約束（physical restraint）」，需要醫師開立醫囑並進行定期評估。若無必要，絕對禁止使用四邊護欄，否則將面臨嚴重的法律與醫療責任問題。