護理師應採取哪些措施以預防高齡病人跌倒？（選所有適合的）
Which of the following actions should the nurse implement to prevent falls in an elderly client? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將床維持在最低位置。
- BEncourage the client to wear non-skid footwear✓ 正解鼓勵個案穿著防滑鞋。
- CPlace personal items within reach✓ 正解將個人物品放置在伸手可及之處。
- DApply physical restraints to keep the client in bed使用身體約束具將個案固定在床上。
- EEnsure the call light is functional and accessible✓ 正解確保呼叫鈴功能正常且易於取得。
預防高齡病人跌倒是護理師的核心職責，需採取多面向的預防策略（Fall Precautions）。核心思路在於移除環境危險因子、增加支持性輔助，以及維持病人與呼叫鈴的連結。約束（Restraints）屬於限制病人自由的介入，必須符合法律規範及醫師醫囑，僅在其他替代方案無效且病人有立即危險時作為最後手段，絕非預防跌倒的常規措施。
Fall prevention in elderly clients requires multifaceted strategies. Core principles include removing environmental hazards, providing supportive aids, and maintaining the client's connection to the call light. Restraints limit autonomy and must follow legal requirements and physician orders; they are a last resort when alternatives fail and the client poses immediate danger—they are never a routine fall prevention measure.
在美國，對約束（Physical Restraints）的規範極為嚴格（CMS標準），需由醫師評估且有時間限制的醫囑，並嚴格記錄監測情形。台灣臨床常見為了防止老人下床而給予約束，但在NCLEX考試中，這被視為侵權且違反安全原則。