護理師為有跌倒史的病人規劃照護計畫，應包含哪些措施？（選所有適合的）
A nurse is planning care for a client with a history of falls. Which actions should the nurse include in the plan of care? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- BPlace the client in a room far from the nurses' station將客戶安置在遠離護理站的房間
- CEnsure call light is within reach✓ 正解確保呼叫鈴在可及範圍內
- DKeep the floor clear of clutter✓ 正解保持地面清除雜物
- EApply soft physical restraints to prevent getting out of bed應用軟性身體約束帶以防止客戶下床
預防跌倒的黃金準則在於移除環境阻礙與維持病人安全距離。病床維持低位可減輕若跌倒時的衝擊；護理呼叫鈴隨手可得能增加病人的安全感並減少擅自下床；環境清潔可移除絆倒物。離護理站遠的病房不便監測；約束非預防跌倒首選，應考量使用警報器等非侵入性措施。
The golden rule of fall prevention is to remove environmental obstacles and maintain a safe distance for the client. Keeping the bed in the lowest position reduces the impact if a fall occurs; keeping the call light within reach enhances the client's sense of security and reduces unassisted attempts to get out of bed; a clear environment removes tripping hazards. A room located far from the nurses' station makes monitoring difficult. Restraints are not the first choice for fall prevention; non-invasive measures such as bed alarms should be considered first.
美國法規對約束限制極嚴（需醫師即時醫囑與定期評估）；台灣較常見為了安全而採取約束，但近年評鑑標準已趨於嚴格。