照護跌倒風險高的病人時，護理師應採取哪些措施？（選所有適合的）
Which of the following interventions are appropriate for a nurse to implement when caring for a client with a risk for falls? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將床置於最低位置
- BPlace the call light within easy reach✓ 正解將呼叫鈴放在容易拿取之處
- CApply physical restraints to prevent movement使用身體約束以防止移動
- DEncourage the client to call for assistance before getting up✓ 正解鼓勵病人在起身前請求協助
- EEnsure the floor is free of clutter✓ 正解確保地面無雜物
跌倒預防核心在於環境改善與行為提醒。保持低床位、呼叫鈴在側、要求下床前呼叫協助、移除障礙物均為實證有效的預防措施。C 選項（身體約束）是最後手段，僅在病人安全受極大威脅且所有替代方案無效時才可使用，不能直接當作常規預防措施。
Fall prevention focuses on environmental modification and behavioral cues. Keeping the bed in the lowest position, placing the call light within reach, instructing the client to call for assistance before getting up, and removing clutter are all evidence-based preventive measures. Option C (physical restraints) is a last resort and may only be used when the client's safety is severely threatened and all alternatives have failed; restraints cannot be implemented as a routine preventive intervention.
美國醫院極度強調防跌措施與指標追蹤（Fall incidence rate）；台灣臨床同樣重視，但在約束使用規範上，美國法規更趨嚴格。