— 降低風險 · EASY · SATA —
護理師為一位有跌倒風險的長者進行安全評估，應執行哪些護理措施？（選所有適合的）
A nurse is conducting a safety assessment for an elderly client at risk for falls. Which interventions should the nurse implement? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解保持床位在最低位置
- BPlace call light within reach✓ 正解將呼叫鈴放置在可觸及之處
- CApply physical restraints to keep the client in bed使用身體約束具將病人固定在床上
- DKeep the environment free of clutter✓ 正解保持環境無雜物
- EEnsure adequate lighting in the room✓ 正解確保室內有充足照明
— Explanation · 中文詳解 —
針對跌倒風險高的病人，護理措施應以「環境改善」與「病人安全」為主。包括降低床位、確保呼叫鈴可及、移除障礙物以減少絆倒、加強照明以確保視覺清晰。選項 C 錯誤：身體約束是最後手段，僅在病人有嚴重自傷或傷人傾向且其他措施無效時才使用，不能作為常規防跌措施。
To prevent falls in elderly clients, nurses should maintain the bed in the lowest position to minimize injury risk, keep the call light within reach for easy assistance, remove environmental clutter to prevent tripping, and ensure adequate lighting for safe navigation. Physical restraints are contraindicated as they increase injury risk and should only be used as a last resort.
✦ 台美臨床差異
美國護理機構極重視約束減免（Restraint-free）；台灣對於高齡病人若有躁動行為，實務上仍常較快採取約束保護。