— 基本照護與舒適 · MEDIUM · SATA —
一位病人跌倒風險很高。護理師應在跌倒預防計畫中包含哪些措施？（選所有適合的）
A client is at high risk for falls. Which interventions should the nurse include in the fall prevention protocol? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解保持病床處於最低位置
- BEnsure the call light is within reach✓ 正解確保呼叫鈴在病人觸手可及之處
- CApply physical restraints for safety為安全起見使用身體約束
- DKeep the room free of clutter✓ 正解保持房間內無雜物
- EPlace a night light in the bathroom✓ 正解在浴室放置夜燈
— Explanation · 中文詳解 —
跌倒預防的核心在於環境控制與病人教育。低床位、易取得的呼叫鈴、無障礙空間與適當照明是標準做法。約束（Restraints）屬於最後手段，僅在病人有攻擊行為或移除醫療設備的極端情況下使用，絕非作為預防跌倒的常規手段。
Fall prevention protocols prioritize environmental safety and patient independence. Keeping the bed low, ensuring call light accessibility, maintaining a clutter-free room, and providing adequate lighting are standard interventions to reduce fall risks. Physical restraints are not used for fall prevention as they can increase injury risk.
✦ 台美臨床差異
美國法規對約束限制極嚴（需嚴格評估與醫囑）；台灣臨床護理師對約束之使用亦需遵循評估流程，但常見於預防跌倒之保護性措施。