— 安全與感染控制 · EASY · SATA —
針對有跌倒風險的病人，下列哪些安全措施應被優先執行？（選所有適合的）
Which of the following client safety measures are prioritized for a client at risk for falls? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床維持在最低位置
- BMaintain call light within reach✓ 正解將呼叫鈴保持在病人可及範圍內
- CApply physical restraints to prevent movement使用身體約束以防止活動
- DKeep the floor free of clutter✓ 正解保持地面無雜物
- EApply non-skid socks or footwear✓ 正解穿著防滑襪或鞋具
— Explanation · 中文詳解 —
預防跌倒的介入措施應以「最小侵入性」與「環境調整」為優先（Least Restrictive Environment）。NCLEX 強調身體約束（physical restraint）是最後手段，僅在病人有危險行為且其他方法無效時才可考慮。優先措施應聚焦於環境安全、輔助工具使用以及病人的可及性需求。
Fall-prevention interventions should prioritize the "least restrictive" and "environmental modification" approaches (Least Restrictive Environment). NCLEX emphasizes that physical restraints are a last resort, used only when a client demonstrates dangerous behavior and other measures have failed. Priority interventions should focus on environmental safety, use of assistive devices, and accessibility for the client.