病房內一位病人跌倒風險評分為 15 分（高風險）。下列哪些護理措施適切？（選所有適合的）
A client on the unit has a fall risk score of 15 (high risk). Which nursing interventions are appropriate? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將床置於最低位置
- BPlace a call light within reach✓ 正解將呼叫鈴放置於病人可及之處
- CInstruct the client to call for help before getting up✓ 正解指示病人在起身前先呼叫協助
- DApply physical restraints to prevent getting out of bed施加身體約束以防止病人下床
- EEnsure adequate lighting in the room✓ 正解確保室內有充足照明
高跌倒風險病人的照護重點在於建立安全的物理環境與提供適當的防護措施。維持床位在最低高度可減少墜床傷勢；呼叫鈴在手邊可避免病人自行下床；教導病人呼叫協助可加強安全意識；充足的照明則能減少因視線不佳導致的絆倒。約束（Restraints）屬於限制病人自主權的最後手段，僅在病人有生命危險或嚴重暴力行為時才考慮，不應作為預防跌倒的常規手段。
Care of patients at high risk for falls focuses on establishing a safe physical environment and providing appropriate protective measures. Keeping the bed in the lowest position reduces injuries from falls; placing the call bell within reach prevents the patient from getting out of bed unassisted; teaching the patient to call for help reinforces safety awareness; and adequate lighting reduces tripping caused by poor visibility. Restraints, which limit the patient's autonomy, are a last resort and should be considered only when there is a threat to life or serious violent behavior; they should not be used as a routine measure to prevent falls.