護理師為高跌倒風險病人規劃護理計畫，應包含哪些措施？（選所有適合的）
A nurse is planning care for a client who is at high risk for falls. Which interventions should be included in the care plan? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- BPlace the client in a room far from the nurses' station將個案安排在遠離護理站的房間
- CEnsure call light is within reach✓ 正解確保呼叫鈴在可觸及範圍內
- DApply physical restraints to keep the client in bed使用身體約束將個案固定在床上
- EEncourage the use of non-slip footwear✓ 正解鼓勵使用防滑鞋具
跌倒是住院病人常見的意外傷害，尤其對於老年人、虛弱或服用特定藥物的病人，跌倒風險更高。預防跌倒是護理的重要職責，需透過多面向的環境與照護措施來降低風險。 核心概念是「移除跌倒誘因」與「增加病人安全」。正確答案 A, C, E 都是基於此原則。選項 A（維持床鋪最低位）可縮短病人跌落床鋪的高度，降低受傷程度；選項 C（確保呼叫鈴在可及處）讓病人需要協助時能及時求助，避免自行下床；選項 E（鼓勵穿著防滑鞋）可增加行走時的穩定性，防止滑倒。 錯誤選項 B（將病人安排在遠離護理站的房間）與預防跌倒的原則相悖。病人離護理站越遠，護理人員越難即時監測其狀況，增加跌倒發生時的反應延遲。選項 D（使用約束帶）是最後手段，需經醫師醫囑，且有嚴格的使用規範與監測要求，並非例行性的預防措施，反而可能因病人掙扎而增加跌倒或受傷風險。
Falls are a common cause of accidental injury in hospitalized clients, and the risk is especially high among older adults, frail individuals, and those taking certain medications. Fall prevention is an important nursing responsibility and must be addressed through multifaceted environmental and care measures to reduce risk. The core principle is to "remove fall triggers" and "increase patient safety." The correct answers A, C, and E are all grounded in this principle. Option A (keeping the bed in its lowest position) reduces the height of any potential fall and minimizes injury severity; option C (ensuring the call light is within reach) allows the client to summon help promptly when assistance is needed, avoiding unaided ambulation; option E (encouraging the use of non-slip footwear) increases stability when walking and prevents slipping. The incorrect option B (placing the client in a room far from the nursing station) contradicts fall prevention principles. The farther the client is from the nursing station, the harder it is for staff to monitor in real time, increasing response delay if a fall occurs. Option D (using restraints) is a measure of last resort that requires a physician's order with strict guidelines for use and monitoring; it is not a routine preventive measure and may actually increase the risk of falls or injury due to client struggling.