護理師為跌倒高風險病人規劃照護計畫，哪些護理措施能有效降低風險？（選所有適合的）
A nurse is planning care for a client at high risk for falls. Which nursing actions are appropriate to reduce the risk? (Select all that apply.)
- AKeep the hospital bed in the lowest position✓ 正解將病床調整至最低位置
- BPlace frequently used items within reach✓ 正解將常用物品放置在伸手可及之處
- CApply physical restraints to keep the client in bed使用身體約束帶以確保病人留在床上
- DEnsure adequate lighting in the room✓ 正解確保室內有充足的照明
- EEncourage the client to wear non-slip footwear✓ 正解鼓勵病人穿著防滑鞋
降低跌倒風險的核心是創造安全的環境。低床位可減少墜落高度；物品隨手可得減少下床次數；充足光線降低障礙物碰撞；防滑鞋具增加抓地力。選項 C 使用約束會增加躁動與受傷機率，除非有明確醫囑且窮盡其他手段才使用，非優先建議。
The core of fall risk reduction is creating a safe environment. A low bed position reduces the height of any fall; keeping items within reach reduces the number of times the client needs to get out of bed; adequate lighting reduces collisions with obstacles; and non-slip footwear improves traction. Option C is not recommended as a first-line intervention because restraints can increase agitation and the likelihood of injury; restraints should only be used with a clear order after all other measures have been exhausted.
美國嚴格規範約束使用評估；台灣在照護過程中仍常將約束視為預防跌倒的積極手段，雖然此觀念正逐漸改變中。