— 降低風險 · EASY · SATA —
下列哪些措施適用於一位有多次跌倒史的病人？（選所有適合的）
Which of the following interventions are appropriate for a client with a history of frequent falls? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將床置於最低位置
- BMaintain a clutter-free environment✓ 正解維持無雜物的環境
- CApply four-sided bed rails to keep the client in bed使用四面床欄以防止病人墜床
- DEncourage the client to call for assistance before getting up✓ 正解鼓勵病人在起身前呼叫協助
- EPlace the client in a room near the nurses' station✓ 正解將病人安置在靠近護理站的病房
— Explanation · 中文詳解 —
跌倒預防強調維持病人行動安全與環境整潔。床低位、環境淨空、呼叫援助、近護理站監測皆為標準策略。四面床欄（C）屬於約束行為，除非有醫療指徵，否則不得作為防止跌倒的手段，且反而可能增加病人攀爬導致嚴重墜落的風險。
Fall prevention emphasizes maintaining safe client mobility and a clear environment. Keeping the bed low, removing clutter, ensuring call-light availability, and placing the client near the nursing station for observation are all standard strategies. Four-side rails (C) constitute a form of restraint and may not be used as a fall-prevention measure unless medically indicated; conversely, they may increase the risk of severe falls when the client attempts to climb over them.
✦ 台美臨床差異
美國法規對約束（四面床欄）的審核非常嚴格，台灣部分護理機構在約束定義上仍有改善空間。