— 降低風險 · EASY · SATA —
護理師評估病人的跌倒風險，下列哪些介入措施能降低風險？（選所有適合的）
A nurse is evaluating a client's fall risk. Which interventions are appropriate to reduce risk? (Select all that apply.)
- APlace the call light within reach✓ 正解將呼叫鈴放在觸手可及之處
- BKeep the bed in the lowest position✓ 正解保持病床處於最低位置
- CKeep the room lights off at night夜間關閉房間燈光
- DEncourage the use of non-slip socks✓ 正解鼓勵穿著防滑襪
- EApply soft wrist restraints使用軟質手腕約束帶
— Explanation · 中文詳解 —
預防跌倒措施包括維持環境安全（如燈光充足而非關燈）、病床調低、呼叫鈴在手邊以及使用防滑鞋襪。約束（E）屬於限制身體自由，除非病人有極度攻擊或危險行為，否則不能作為單純防跌措施使用，且約束反而增加焦躁風險。
Fall-prevention measures include maintaining a safe environment (such as adequate lighting rather than turning the lights off), keeping the bed in the lowest position, placing the call light within reach, and using non-slip footwear. Restraints (E) restrict body movement and, except in cases of extreme aggression or dangerous behavior, should not be used solely as a fall-prevention measure; restraints in fact increase agitation and the resulting risk.
✦ 台美臨床差異
美國法規對約束（Restraints）的使用限制非常嚴格，必須有醫師具時效性的醫囑；台灣醫院規範亦日益嚴格。