護理師照護一位意識混亂且反覆嘗試下床的老年病人。為確保病人安全，護理師應優先採取哪些措施？（選所有適合的）
A nurse is caring for an older adult client who is confused and repeatedly attempts to get out of bed. Which actions should the nurse implement first to ensure safety? (Select all that apply.)
- AApply soft wrist restraints to prevent the client from leaving the bed使用軟質手腕約束帶以防止病人離開病床
- BPlace the bed in the lowest position✓ 正解將病床調至最低位置
- CMove the client's room closer to the nurses' station✓ 正解將病人的房間移至靠近護理站的位置
- DRequest a prescription for a sedative medication申請鎮靜劑處方
- EUse a bed alarm system to alert staff when the client moves✓ 正解使用床邊警報系統以在病人移動時通知護理人員
在管理跌倒風險與維護病人安全時，「最小限制原則」（Least Restrictive Environment）是核心。護理師應優先使用非侵入性且非限制性的干預措施。選項 B（降低床位高度）、C（移至護理站附近的房間）與 E（使用床邊警報器）都是有效的安全防範措施，且不會剝奪病人的行動自由或造成生理損傷。選項 A（約束）與 D（鎮靜藥物）被視為最後手段，且在美國護理實務中，實施約束前必須經過多種替代方案嘗試失敗後，並取得醫師限時醫囑才能執行。此題測驗護理師是否能區分「預防措施」與「限制性處置」，並選擇對病人尊嚴與自主性損害最小的方法。
In managing fall risk, the 'least restrictive environment' principle is central. The nurse should first use non-invasive, non-restrictive interventions. Options B (lowering the bed), C (room near the nurses' station), and E (bed alarm) are effective safety measures that do not restrict freedom or cause injury. Options A (restraints) and D (sedative) are last-resort measures; in U.S. nursing practice, restraints may only be applied after less restrictive alternatives have failed and with a time-limited physician order. This question distinguishes 'preventive measures' from 'restrictive interventions' and emphasizes preserving dignity and autonomy.
美國醫院對於「Restraint-free environment」（無約束環境）有極嚴格的法規與評鑑標準（如 Joint Commission），必須每 2 小時評估並頻繁更新醫囑；台灣醫院雖也推行減少約束，但在人力不足或家屬要求下，約束的使用比例有時相對較高，且法律程序上的嚴謹度與美國仍有差異。