護理師正在檢視一位跌倒高風險病人的照護計畫。應包含哪些介入措施？（選所有適合的）
The nurse is reviewing the plan of care for a client who is at high risk for falls. Which interventions should be included? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- BPlace a 'High Fall Risk' sign at the doorway✓ 正解在門口放置「高跌倒風險」標示
- CKeep all four side rails in the upright position將四邊床欄全部拉起
- DEnsure the call light is within reach✓ 正解確保呼叫鈴在可觸及範圍內
- EProvide nonskid socks for ambulation✓ 正解提供防滑襪供步行使用
跌倒預防是一項多面向的安全措施。選項 A（低床位）能減少萬一跌落時的傷害。選項 B（警示標誌）提醒所有工作人員注意。選項 D（呼叫鈴在手邊）讓病人需要幫助時能求援，減少自行下床的衝動。選項 E（防滑襪）增加行走時的抓地力。選項 C（四床欄全拉）在 NCLEX 邏輯中被視為「物理約束（Physical Restraint）」，除非有特殊醫療理由，否則全拉床欄會讓病人試圖從床尾爬出，反而增加跌落高度與受傷嚴重性。臨床思維應側重於環境支持與適度限制，而非全面封鎖。
Fall prevention is a multifaceted safety measure. Option A (low bed position) reduces injury should the patient fall. Option B (warning signs) alerts all staff members. Option D (call light within reach) allows the patient to summon help when needed, reducing the impulse to get out of bed unassisted. Option E (nonslip socks) increases traction during ambulation. Option C (all four side rails up) is considered a physical restraint under NCLEX reasoning; unless there is a specific medical indication, raising all four side rails may cause the patient to attempt climbing over the foot of the bed, paradoxically increasing the height of any fall and the severity of injury. Clinical reasoning should emphasize environmental support and appropriate restriction rather than total confinement.
在美國，全拉床欄（4 rails up）被嚴格定義為 Restraint，需要醫囑並有頻繁監測紀錄。台灣許多病房仍習慣將 4 床欄全拉作為「保護」病人的手段，這在 NCLEX 考試中必須區分開來，絕對不能選。