為確保病人環境安全並預防跌倒，護理師應採取哪些措施？（選所有適合的）
Which actions should the nurse take to ensure a secure client environment and prevent falls? (Select all that apply.)
- AKeep the call light within the client's reach✓ 正解將呼叫鈴保持在病人觸手可及之處
- BEnsure the bed is in the lowest position✓ 正解確保病床處於最低位置
- CRemove excess equipment and clutter from the room✓ 正解清除房間內多餘的設備和雜物
- DApply physical restraints to all elderly patients對所有老年病人實施身體約束
- EPlace the client on a routine toileting schedule✓ 正解讓病人遵循規律的如廁時間表
跌倒預防屬於 Reduction of Risk Potential 的範疇。預防重點在於消除環境中的隱患（如障礙物）、降低發生跌倒後的嚴重程度（如降至低床位）、提供病人求助的管道（呼叫鈴），以及針對生理性風險因子進行管理（如常規如廁計畫，因頻繁下床如廁是跌倒高峰）。約束（Restraints）應是最後手段，僅在確實危害安全且經醫師評估後使用，絕非預防跌倒的常規手段。
Fall prevention falls under Reduction of Risk Potential. The emphasis is on eliminating environmental hazards (such as obstacles), reducing the severity of falls when they occur (such as lowering the bed), providing the patient with a means to call for help (call bell), and managing physiologic risk factors (such as a scheduled toileting plan, since frequent unassisted trips to the bathroom are peak times for falls). Restraints should be a last resort, used only when safety is clearly threatened and after physician evaluation; they are not a routine fall-prevention strategy.
美國對於 Restraints 使用規範極嚴（遵循 Joint Commission 標準），護理師若非經醫師開立醫囑且評估必要性，絕對不得自行對病人施加約束，否則涉及非法拘禁（False Imprisonment）。