護理師正在督導一位協助照護員（AP）照護有跌倒病史的病人。AP 的哪項行為需要護理師立即介入？
A nurse is supervising an assistive personnel (AP) who is providing care to a client with a history of falls. Which action by the AP requires immediate intervention by the nurse?
- ALeaving the bed in the lowest position將床維持在最低位置
- BClearing the pathway to the bathroom清除通往浴室的通道
- CKeeping the call light within the client's reach將呼叫鈴保持在病人可及範圍內
- DLeaving the side rails up on both sides of the bed✓ 正解將床兩側的床欄全部升起
對於有跌倒病史的病人，護理安全的首要目標是降低環境風險。將兩側床欄全升起在臨床上被視為一種限制性措施（Restraint），若病人試圖跨越床欄，反而會增加從高處跌落並導致嚴重頭部損傷的機率。護理師應評估病人是否真的需要床欄，對於混亂或高風險病人，應採取更安全且非限制性的替代方案，如低位床或監測警報器。
For clients with a history of falls, the primary nursing safety goal is to reduce environmental risk. Raising all side rails on both sides of the bed is clinically considered a form of restraint; if the client attempts to climb over the rails, the risk of falling from a greater height and sustaining serious head injury actually increases. The nurse should evaluate whether the client truly requires side rails, and for confused or high-risk clients should adopt safer, non-restrictive alternatives such as a low bed or bed-exit alarms.
在美國臨床，將兩側床欄全升起（all side rails up）通常被法律認定為一種身體約束（Restraint），需有醫師醫囑並定期評估。台灣醫療環境中，床欄常被視為預防跌倒的基本設施，兩者對其危險性的認知有顯著差異。