護理師正在檢視一位高跌倒風險高齡病人的照護計畫，應包含哪些介入措施？（選所有適合的）
The nurse is reviewing the plan of care for an elderly client at high risk for falls. Which interventions should be included? (Select all that apply.)
- AKeep the hospital bed in the lowest position✓ 正解將醫院病床保持在最低位置
- BPlace a bedside commode near the client's bed✓ 正解在病人床邊放置床邊便盆椅
- CEnsure the room has adequate lighting at all times✓ 正解確保房間隨時有充足的照明
- DApply four side rails to the bed to prevent the client from getting up在床鋪上安裝四片床欄以防止病人起身
- EEnsure the client wears non-skid footwear when ambulating✓ 正解確保病人在行走時穿著防滑鞋
核心概念：跌倒預防的多維度策略。跌倒通常是多因素造成的，因此預防介入也必須包含環境改善、工具輔助與行為指導。為何正確答案對：選項 A 降低高度可減少落地衝擊；B 減少如廁路程；C 增加視線清晰度；E 增加摩擦力防止滑倒。為何其他選項錯：選項 D 使用四個床欄在美國 NCLEX 考試標準中被視為非法限制（restraint），且病人若嘗試爬過床欄掉下來，摔傷會更嚴重。臨床思路：護理師應採取「最少限制」原則（Least Restrictive Environment），並針對病人的具體風險點（如夜尿、視力不佳、步伐不穩）進行個別化干預。
Fall prevention requires a multifactorial strategy combining environmental modification, assistive devices, and behavior guidance. Keeping the bed in the lowest position (A) reduces the height if a fall occurs; a bedside commode (B) shortens the walking distance, especially at night; adequate lighting (C) compensates for age-related visual decline; non-skid footwear (E) increases traction on hospital flooring. Raising all four side rails (D) is considered a restraint under NCLEX standards and can lead to more serious injuries if the client climbs over them. The nurse should apply the least-restrictive approach and individualize interventions based on specific risk factors (nocturia, vision, gait).
美國 NCLEX 考試中，除非有特定醫囑，否則四個床欄絕對被視為 Restraint；台灣臨床實務上，為防止跌倒，拉起全部床欄仍是許多病房的常規做法，這點在準備美國考照時需特別區分。