護理師為高跌倒風險病人規劃照護計畫，應包含哪些策略？（選所有適合的）
A nurse is planning care for a client at high risk for falls. Which strategies should be implemented? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- BPlace a call light within reach✓ 正解將呼叫鈴放置在可及範圍內
- CEncourage the client to get up quickly to avoid dizziness鼓勵客戶快速起身以避免眩暈
- DOrient the client to the room environment✓ 正解引導客戶熟悉房間環境
- EApply soft physical restraints to keep the client in bed使用軟性身體約束帶使客戶留在床上
跌倒防護重點在於環境調整與病人教育。低床位可減緩跌倒衝擊；呼叫鈴在手邊能即時求援；環境熟悉度減少因迷路產生的移動風險。不可鼓勵快速起身，因為姿勢性低血壓會增加跌倒機率。約束非跌倒防護的首選策略，應先評估動機與協助需求。
Fall prevention focuses on environmental modification and client education. A low bed position reduces the impact if a fall occurs; a call light within reach allows immediate requests for assistance; and familiarity with the environment reduces the risk of movement caused by disorientation. Clients should not be encouraged to stand up quickly, because orthostatic hypotension increases fall risk. Restraints are not the first-line fall prevention strategy; the nurse should first assess the client's motivation and need for assistance.
美國法規對於約束（restraint）使用限制極嚴，台灣在臨床上對於高風險病人的約束使用率仍偏高，但兩地皆傾向於推廣非約束性的防跌策略。