照顧跌倒高風險病人時，哪些護理措施是適當的？（選所有適合的）
Which of the following interventions are appropriate when caring for a client who is identified as a fall risk? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將床置於最低位置
- BEnsure the call light is within the client's reach✓ 正解確保呼叫鈴在病人可及範圍內
- CApply four-point side rails to prevent the client from getting out of bed安裝四邊床欄以防止病人下床
- DPlace the client in a room near the nursing station✓ 正解將病人安置在靠近護理站的房間
- EApply non-skid socks to the client's feet✓ 正解為病人穿著防滑襪
預防跌倒的措施應包含環境調整與病人監測。保持病床低位、呼叫鈴在手邊、將病人安排在護理站附近以利觀察、穿著防滑襪均為標準作業。選項 C（四面床欄）屬於身體約束，並非預防跌倒的常規措施，反而可能造成病人試圖跨越而導致更嚴重的跌倒傷害。
Fall prevention measures should include environmental modification and client monitoring. Keeping the bed in the lowest position, placing the call bell within reach, locating the client near the nursing station for observation, and providing non-slip socks are all standard practices. Option C (four-side rails) constitutes physical restraint and is not a routine fall-prevention measure; instead, it may lead the client to attempt to climb over and suffer a more severe fall injury.
在台灣，四面床欄常被視為照顧常規，但在美國屬於約束管理（Restraint），需嚴格臨床評估與開立醫囑。