護理師觀察到一位病人試圖下床時顯得掙扎。為預防跌倒，應優先採取哪項措施？
A nurse observes a client struggling to get out of bed. Which safety measure should be prioritized to prevent falls?
- AAssign a sitter to the room指派專責看護至病房
- BApply a vest restraint應用背心式約束帶
- CKeep the bed in the lowest position✓ 正解保持病床處於最低位置
- DRaise all four side rails升起全部四片床欄
預防跌倒的基本原則是維持環境安全，確保床位維持在最低位置，以便病人雙腳能平穩著地。升起所有四個床欄（D）可能造成病人試圖翻越導致更嚴重的跌倒，屬於約束限制；約束物（B）需醫師醫囑且有適應症；陪病者（A）並非第一線環境安全措施。
The basic principle of fall prevention is to maintain a safe environment, ensuring that the bed remains in the lowest position so that the client can place both feet steadily on the floor. Raising all four side rails (D) may cause the client to try to climb over them, resulting in a more serious fall, and constitutes a form of restraint; restraints (B) require a physician's order and an appropriate indication; a sitter (A) is not a first-line environmental safety measure.
美國護理界非常強調「零約束」（Zero Restraint）政策；台灣臨床實務上，護理師因人力不足，有時會傾向使用約束來防止跌倒，需法規嚴格把關。