護理師正在審視一位跌倒高風險病人的照護計畫。下列哪些干預措施應包含在內？（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 the nurse include? (Select all that apply.)
- APlace the bedside table within the client's reach✓ 正解將床邊桌置於病人可觸及範圍內
- BKeep the bed in the lowest position✓ 正解保持床位在最低位置
- CLock the wheels on the bed and wheelchair✓ 正解鎖定床與輪椅的輪子
- DApply four side rails to the bed as a reminder拉起四側床欄作為提醒
- EProvide non-skid socks for ambulation✓ 正解提供防滑襪供步行時穿著
跌倒預防的重點在於『環境優化』與『可及性』。A 正確，因為物品手拿得到可減少病人因探身而失去平衡。B（床降至最低）與 C（輪子固定）是基本的物理安全。E（防滑襪）提供行走時的摩擦力。D 是錯誤陷阱：在美國護理標準中，『四個床欄全部拉起』被視為一種約束（Restraint），可能會增加病人翻越床欄而摔得更重的情形，除非有特殊醫療指示，否則不建議作為預防跌倒的常規手段。核心概念是：預防跌倒應採最少限制性的方法。
Fall prevention strategies include placing the bedside table within reach to avoid overreaching, keeping the bed in the lowest position to minimize fall height, locking wheels for stability, and providing non-skid socks for traction. Raising all four side rails is contraindicated as it is considered a restraint and may increase injury risk.
在美國，全床欄（Four side rails）受到嚴格法律限制，需有醫囑且被視為約束；台灣臨床上為了防跌，常態性拉起四個床欄的習慣仍普遍，這在 NCLEX 考試中是常見的觀念衝突點。