一位85歲患有輕度阿茲海默症的女性因嚴重的泌尿道感染合併譫妄住院。在大夜班期間，她不斷試圖拔除點滴管，聲稱那是一條蛇。護理師走進病房時，發現病患在一陣嚴重的全身無力下，仍將一條腿跨越床欄，試圖獨自去上廁所。生命徵象：血壓 110/60 mmHg，體溫 38.0°C。為了預防跌倒，護理師應首先執行下列哪項介入措施？
An 85-year-old female with mild Alzheimer's disease is hospitalized for a severe UTI complicated by delirium. During the night shift, she repeatedly attempts to pull out her IV line, claiming it is a snake. The nurse walks in to find the patient with one leg positioned over the side rail, attempting to use the restroom alone despite profound generalized weakness. Vital signs: BP 110/60 mmHg, Temp 38.0°C (100.4°F). Which intervention should the nurse implement first to prevent a fall?
- AApply bilateral soft wrist restraints to prevent the patient from removing the IV line.應用雙側軟式手腕約束帶以防止病人移除靜脈輸液管。
- BAdminister the PRN dose of haloperidol to sedate the patient through the night.給予 PRN 劑量的 haloperidol 以鎮靜病人過夜。
- CActivate an electronic bed-exit alarm and move the patient's room closer to the nurses' station.✓ 正解啟動電子離床警報並將病人房間移至護理站附近。
- DRaise all four side rails of the bed to physically block the patient from exiting the bed.拉起四個床欄以物理方式阻止病人離開床鋪。
本題測試預防跌倒的「最低限制性原則（Least Restrictive Means）」。當面對具備高跌倒風險且認知混亂的老年患者時，護理師必須窮盡所有非約束性的替代方案才能考慮使用物理或化學約束。選項A（手部約束）會增加病患的焦慮並使譫妄惡化；選項D（拉起四側床欄）在美國法規上被定義為明確的物理約束（Physical Restraint），且若病患試圖翻越而墜落時，會造成更嚴重的頭部或脊椎損傷；選項B（給予抗精神病藥鎮靜）屬於化學約束（Chemical Restraint），除非有立即攻擊危險，否則不應作為常規防跌手段首選。選項C啟動離床警報器結合提高監測頻率（移近護理站），是最安全且最低干預性的第一線預防跌倒標準介入。
This question tests the 'least restrictive means' principle for fall prevention in a confused older adult with delirium. (A) wrist restraints worsen delirium and do not prevent legs from going over a rail; (D) four side rails up function as a physical restraint and increase injury severity if the patient climbs over; (B) PRN haloperidol used purely for restraint is chemical restraint and inappropriate as a first measure. (C) bed-exit alarm and moving the patient closer to the nurses' station provide maximal monitoring while respecting the least restrictive standard and is the correct first intervention.
美國法規 CMS 極度嚴格審查「約束的使用」，不僅四側床欄視為約束，約束導致的跌倒會被重罰；台灣雖然也推動零約束，但在長照與一般病房，為了防範家屬責難或人力不足，拉起四側床欄或使用乒乓球手套防護仍頻繁可見。