護理師評估某病人跌倒風險高，應包含哪些護理措施？（選所有適合的）
A nurse identifies 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✓ 正解將床置於最低位置
- BEncourage the client to use a walker✓ 正解鼓勵病人使用助行器
- CPlace the call light within reach✓ 正解將呼叫鈴放在伸手可及處
- DApply four-side bed rails安裝四側床欄
- EProvide non-slip footwear✓ 正解提供防滑鞋
預防跌倒的黃金守則包括物理環境調整與輔助工具使用。降低床位高度能減少墜落距離；保持呼叫鈴隨手可得能讓病人無需勉強起身；使用助行器提高支撐性；防滑鞋增加摩擦力。選項 D 屬於約束限制，非預防跌倒的例行手段，需具備醫療評估。
The golden rules of fall prevention include modifying the physical environment and using assistive devices. Lowering the bed height reduces the distance of a possible fall; keeping the call light within reach allows the client to avoid getting up unassisted; using a walker enhances support; and non-slip footwear increases friction. Option D belongs to physical restraint and is not a routine fall-prevention measure; it requires medical assessment.
美方對於「約束」定義嚴格，四側床欄在多數醫院視為身體約束；台灣臨床對於四側床欄使用較為寬鬆，但需評估病人行為。