護理師正在審查一位高跌倒風險病人的護理計畫。應包含哪些措施？（選所有適合的）
The nurse is reviewing the plan of care for a client who is at risk for falling. Which interventions should be included? (Select all that apply.)
- AKeep the bed in the lowest position.✓ 正解將床置於最低位置
- BLock the wheels on the bed and wheelchair.✓ 正解鎖定床和輪椅的輪子
- CKeep all four side rails in the up position.將四個床欄全部拉起
- DPlace a call light within the client's reach.✓ 正解將呼叫鈴放在病人可觸及之處
- EProvide adequate lighting in the client's room.✓ 正解提供病人房間充足的照明
預防跌倒的措施應集中於環境安全與輔助工具的可近性。床位維持最低位置（A）能減少萬一跌落時的衝擊。鎖定輪子（B）防止在病人移位時床或輪椅滑動造成失去平衡。呼叫鈴放在手邊（D）能讓病人有需求時主動尋求幫助，減少自行下床的衝機。充足光線（E）對視力不佳或夜間如廁的病人至關重要。選項 C（拉起所有圍欄）在美國被視為「身體約束」（Restraint），反而可能讓病人嘗試跨越圍欄而從更高處跌落，屬於禁忌。護理重點是創造一個障礙物少且支撐穩固的環境。
To prevent falls, the nurse should keep the bed in the lowest position, lock wheels on beds and wheelchairs, place the call light within reach, and ensure adequate lighting. Raising all four side rails is contraindicated as it is considered a restraint and may encourage the client to climb over them, increasing the risk of injury from a greater height.
美國對於「四邊圍欄」的法律定義極其嚴格，除非是特殊狀況否則視為非法約束。台灣臨床常見四邊全拉，但應逐漸轉變觀念，僅拉起兩側或留出出口，以減少病人因跨越而跌倒的風險。