對於跌倒高風險的病人，下列哪些護理措施是適當的？（選所有適合的）
Which of the following interventions are appropriate for a client who is identified as a high fall risk? (Select all that apply.)
- APlace the call light within the client's reach✓ 正解將呼叫鈴置於病人可觸及之處
- BKeep the bed in the lowest position at all times✓ 正解隨時將病床保持在最低位置
- CApply physical restraints to prevent the client from getting up使用身體約束以防止病人起身
- DEnsure the floor is free of clutter and cords✓ 正解確保地面無雜物與電線
- EOrient the client to the room and call light system✓ 正解協助病人熟悉房間環境與呼叫鈴系統
跌倒預防的核心在於營造安全的物理環境與提升病人的定向感。護理師需透過移除環境障礙物、確保病床處於低位以縮短墜落距離、確保呼叫鈴（Call light）隨手可得以利病人尋求協助，並確保病人對環境熟悉，減少因迷惘而嘗試起床導致的跌倒。物理約束（Physical restraints）不僅可能造成病人的焦慮、約束處損傷，還可能增加跌倒風險，因此僅在窮盡其他安全措施且有醫囑時才使用。
Fall prevention focuses on creating a safe physical environment and enhancing patient orientation. Interventions include keeping the bed in the lowest position to minimize injury from falls, ensuring the call light is within reach, removing environmental hazards like clutter, and orienting the client to their surroundings. Physical restraints are avoided as they can increase agitation and injury risk.
在美國，跌倒預防極度強調證據導向（Evidence-based practice），強制使用床欄（Side rails）在美國通常被視為約束（Restraint），除非是有醫療需求，否則不建議全升，這與台灣常見的四面床欄全升習慣不同。