— 降低風險 · MEDIUM · SATA —
護理師應採取哪些措施，以預防意識混亂的老年病人發生跌倒？（選所有適合的）
Which actions should the nurse take to prevent falls in an elderly client with confusion? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- BProvide bedside commode for frequent toileting✓ 正解提供床邊便盆以便頻繁如廁
- CApply physical restraints securely牢固地應用身體約束
- DOrient the client to the environment frequently✓ 正解經常引導病人適應環境
- EEnsure the call light is within reach✓ 正解確保呼叫鈴在觸手可及之處
— Explanation · 中文詳解 —
預防意識混亂（Confusion）病人跌倒的核心在於提供安全環境與減少焦慮。物理約束（Restraints）為最後手段，僅在病人對他人或自身造成立即傷害且其他措施無效時使用，且需醫師醫囑。其他選項如低床位、呼叫鈴、定向感指導及廁所協助，均屬於預防跌倒的基礎標準程序（Standard precautions）。
Fall prevention strategies for confused clients include keeping the bed in the lowest position, providing easy access to a bedside commode, frequently orienting the client to their environment, and ensuring the call light is within reach. Physical restraints should be avoided as they increase the risk of injury and agitation, serving only as a last resort when other measures fail.