護理師應採取哪些措施來預防高齡病人的跌倒風險？（選所有適合的）
Which of the following interventions should a nurse include in a plan of care to prevent falls in an elderly client? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- BPlace the client in a room far from the nursing station將病人安置在遠離護理站的房間
- CEnsure the call light is within easy reach✓ 正解確保呼叫器在容易觸及之處
- DApply physical restraints to keep the client in bed使用身體約束帶讓病人留在床上
- EMaintain adequate lighting in the room✓ 正解維持室內充足的照明
預防老年人跌倒是護理照護的核心安全目標。介入措施應著重於環境改造與個案安全維護。將病床保持在最低位能縮短跌倒距離；呼叫鈴隨手可及能減少病人因急迫或無助而獨自下床的動機；充足光線則能改善視力輔助，減少因絆倒導致的傷害。護理思路應優先採取非侵入性、低風險的預防措施，約束僅作為保護病人生命安全之最後手段，且需經醫囑與嚴格評估。
Preventing falls in older adults is a core safety goal of nursing care. Interventions should focus on environmental modification and individualized safety. Keeping the bed in the lowest position shortens the distance of a potential fall; keeping the call light within easy reach reduces the client's incentive to get out of bed alone out of urgency or helplessness; and adequate lighting improves visual support and reduces injury from tripping. Nursing reasoning should prioritize non-invasive, low-risk preventive measures, with restraints used only as a last resort to protect the client's life, and only with a physician's order and rigorous assessment.
美國醫院對跌倒風險評估（如 Morse Fall Scale）非常嚴格，且對於約束（Restraints）的使用有極為嚴格的法規限制（如 CMS 指引），必須具備當下醫囑，且每隔一段時間需重新評估，與台灣臨床有時習慣性使用床欄或約束作為預防手段的文化有顯著差異。