一位跌倒高風險病人，護理師應包含哪些護理計畫內容？（選所有適合的）
A nurse is caring for a client who is at high risk for falls. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將床維持在最低位置
- BPlace the call light within reach✓ 正解將呼叫鈴放在病人觸手可及之處
- CApply physical restraints to keep the client in bed使用身體約束具將病人固定在床上
- DClear the room of clutter✓ 正解清除房間內的雜物
- EInstruct the client to call for assistance before getting up✓ 正解指示病人在起身前尋求協助
跌倒預防的核心在於移除環境中的物理障礙並增強病人的溝通與自主安全意識。護理計畫應優先考慮無侵入性、低風險的環境調整。使用約束（Physical Restraints）在美國法律中受嚴格監控（僅限於病人危及自身或他人安全且其他替代方案失效時），非預防跌倒的常規手段。正確的做法是透過環境監測、病人教育及溝通協助來降低風險，確保病人安全。
The core of fall prevention is to remove physical obstacles in the environment and to strengthen the client's communication and personal safety awareness. The plan of care should prioritize non-invasive, low-risk environmental adjustments. Physical restraints are strictly regulated under U.S. law (used only when the client poses a danger to self or others and alternatives have failed) and are not a routine fall-prevention measure. The correct approach is to reduce risk through environmental monitoring, client education, and communication assistance, ensuring patient safety.
美國醫院對約束（Restraints）的使用標準極為嚴格，通常需每 1-4 小時進行評估，且醫師醫囑需每日更新，與台灣臨床對於約束使用較為寬鬆的習慣有明顯法律與實務差異。