為預防一位患有意識混亂的高齡病人跌倒，護理師應採取哪些措施？（選所有適合的）
Which actions should the nurse implement to prevent falls for an older adult client with confusion? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床調整至最低位置
- BPlace a bedside commode near the bed✓ 正解在床邊放置便盆
- CEnsure the client wears non-skid socks✓ 正解確保病人穿著防滑襪
- DRaise all four side rails to keep the client in bed將四側床欄全部拉起以限制病人留在床上
- EProvide adequate lighting in the room at night✓ 正解夜間提供充足的室內照明
跌倒防範是老年護理與安全的核心項目。對於意識混亂（Confusion）的病人，環境改良與生理需求滿足優於強制約束。核心概念包括：降低物理高度、減少行走距離、增加抓地力與視線清晰度。將床降至最低（A）可減輕萬一跌落時的傷害；放置床邊便盆（B）可減少病人因急著上廁所而獨自下床走遠的危險；止滑襪（C）提供必要的摩擦力；夜間光線（E）有助於定向感。選項 D（拉起四個床欄）是 NCLEX 的經典錯誤選項，因為這在法律上被界定為物理約束（Restraint），且可能導致病人試圖翻越更高處跌下，造成更嚴重的骨折或頭部外傷。臨床思路應傾向「最小限制」與「環境支持」。
Fall prevention is a core item in geriatric nursing and safety. For confused clients, environmental modifications and meeting physiologic needs take precedence over physical restraints. Core concepts include: lowering physical height, reducing walking distance, increasing traction, and ensuring clear visibility. Lowering the bed to the lowest position (A) reduces injury in the event of a fall; placing a bedside commode (B) reduces the risk of the client getting out of bed alone to rush to the bathroom; non-slip socks (C) provide necessary friction; and a nightlight (E) helps with orientation. Option D (raising all four side rails) is the classic NCLEX wrong answer because it is legally defined as a physical restraint and may lead the client to attempt to climb over and fall from a higher position, causing more severe fractures or head trauma. The clinical reasoning should favor the least restrictive option and environmental support.
美國非常強調「無約束環境」（Restraint-free environment），四邊床欄的全起受到嚴格法律規範與審核。台灣臨床上為了怕家屬責備，常會習慣性全起床欄，這在 NCLEX 考試中是絕對的紅旗（Red Flag）錯誤行為。