護理師為高跌倒風險病人進行安全評估，下列哪些措施應納入護理計畫？（選所有適合的）
A nurse is conducting a safety assessment for a client at high risk for falls. Which interventions should be included in the care plan? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解保持病床處於最低位置
- BApply physical restraints as a preventive measure將身體約束作為預防措施
- CEnsure the call light is within the client's reach✓ 正解確保呼叫鈴在病人可觸及範圍內
- DPlace the client in a room near the nursing station✓ 正解將病人安置在護理站附近的房間
- EOrient the client to the environment upon admission✓ 正解入院時對病人進行環境定向
防跌措施（Fall Precautions）的核心是環境評估與病人定向。將床位調低以縮短跌倒高度，確保呼叫鈴在手邊以利尋求協助，將高風險病人安排在靠近護理站的房間以利密切觀察，並在入院時協助個案定向（Orient）以熟悉環境，這些都是實證支持的預防跌倒措施。身體約束並非預防跌倒的常規手段，且可能增加病人焦慮與受傷風險。
The core of fall precautions is environmental assessment and patient orientation. Keeping the bed in the lowest position shortens the fall distance, ensuring the call light is within reach allows the client to seek help, placing high-risk clients in rooms near the nursing station permits close observation, and orienting clients to the environment on admission helps them become familiar with their surroundings. These are all evidence-based fall prevention strategies. Physical restraints are not a routine fall prevention measure and may increase the client's anxiety and risk of injury.
美國醫院對於防跌的執行力極高，會使用床邊警報器（Bed alarms）與黃色防跌手環（Yellow fall-risk wristbands）。台灣臨床對於「靠近護理站」的安排有時受限於床位狀況，但在 NCLEX 考試中，這被視為必選的防護措施。