— 照護管理 · MEDIUM · SATA —
護理師應實施哪些干預措施，以預防高齡病人跌倒？（選所有適合的）
Which of the following interventions should a nurse implement to prevent falls in a geriatric client? (Select all that apply.)
- AKeep the call light within the client's reach✓ 正解將呼叫鈴置於病人隨手可及之處
- BApply wrist restraints to keep the client in bed使用手腕約束帶使病人留在床上
- CEnsure the room is well-lit and free of clutter✓ 正解確保房間照明充足且無雜物
- DPerform hourly rounding to assess client needs✓ 正解每小時巡房以評估病人需求
- ESet the bed to the lowest position✓ 正解將病床調整至最低位置
— Explanation · 中文詳解 —
預防跌倒需移除環境因子並提升監測頻率。選項 A、C、D、E 皆為實證基礎的跌倒預防策略。Wrist restraints（腕部約束）為侵入性且限制行動的最後手段，若無嚴重攻擊行為或醫療必要，不可隨意作為防跌手段，否則涉及限制人身自由。
Fall prevention strategies focus on environmental modification and proactive monitoring. Keeping the call light within reach, ensuring well-lit clutter-free rooms, performing hourly rounding, and setting the bed to the lowest position are evidence-based interventions. Wrist restraints are not a fall prevention strategy; they can increase agitation and injury and should only be used as a last resort with proper indications.
✦ 台美臨床差異
美國對約束（restraints）使用管理極嚴，強調 least restrictive environment；台灣約束使用相對較常見。