護理師為跌倒高風險病人規劃照護措施，應包含哪些內容？（選所有適合的）
A nurse is planning care for a client with a history of falls. Which measures should be included in the care plan? (Select all that apply.)
- AKeep the call light within reach at all times✓ 正解呼叫鈴應隨時保持在可觸及範圍內
- BEnsure the room is free of clutter✓ 正解確保房間內無雜物
- CPlace the client in a room far from the nursing station將病人安置在遠離護理站的房間
- DKeep the bed in the lowest position✓ 正解保持床位在最低位置
- EApply physical restraints to keep the patient safe使用身體約束具以確保病人安全
預防跌倒需採用多面向的環境控制措施。核心原則是減少環境障礙物、確保呼叫鈴（Call light）在病人隨手可及處，以及維持床位處於最低高度。安排病人靠近護理站是為了增加觀察頻率。使用約束（Restraints）是最後手段，僅在病人對自己或他人造成立即危險時才考慮，且需嚴格遵循醫師醫囑，因約束會導致病人焦慮、肌力萎縮及皮膚受損。
Fall prevention strategies prioritize environmental safety by keeping the room clutter-free and ensuring the call light is always within the client's reach. The bed should be kept in the lowest position to minimize injury severity if a fall occurs, and the client should be placed near the nursing station for frequent monitoring. Physical restraints are avoided as they increase agitation and fall risk, serving only as a last resort under strict protocols.