護理師照護一位有跌倒風險的病人，護理計畫應包含哪些措施？（選所有適合的）
A nurse is caring for a client who is at risk for falls. Which nursing interventions should be included in the plan of care? (Select all that apply.)
- AKeep the call light within the client's reach✓ 正解將呼叫鈴放在病人可及之處
- BKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- CEncourage the client to get up independently for exercise鼓勵病人獨立下床運動
- DPlace personal belongings within easy reach✓ 正解將個人物品放在容易取得之處
- EApply soft physical restraints to the bed frame在床架上施加軟性物理約束
跌倒預防計畫的核心在於「環境移除障礙」與「增加便利性」。呼叫鈴（Call light）必須隨時在病人手邊，確保其需要時能呼叫協助；床位維持在最低位置，可降低萬一墜床時的傷害高度；私人物品易取，可減少病人嘗試下床獲取物品的衝動。約束病人並非預防跌倒的正規手段，反而可能因病人掙扎導致更嚴重傷害，只有在其他方法無效且具醫療必要時才能評估使用。
The core of a fall prevention plan is to remove environmental hazards and increase accessibility. The call light must always be within the client's reach to ensure they can summon help when needed. Keeping the bed in the lowest position reduces the height of any fall from the bed. Keeping personal belongings within easy reach decreases the urge to get out of bed to retrieve items. Restraining the client is not a standard fall prevention strategy and may cause more serious injury as the client struggles; restraints should only be considered when other methods have failed and there is medical necessity.
美國醫院對於約束（Restraints）的使用有極為嚴格的法規限制，必須有醫師醫囑，並需頻繁評估與記錄。護理師應優先採用非約束性干預措施（Non-restraint interventions），如增加巡視頻率（Rounding）或安排看護（Sitter）。