— 安全與感染控制 · HARD · SATA —
護理師為一位反覆跌倒的病人制定照護計畫，應包含哪些介入措施？（選所有適合的）
A nurse is creating a plan of care for a client with a history of recurrent falls. Which interventions should be included? (Select all that apply.)
- AKeeping the bed in the lowest position✓ 正解保持床位處於最低位置
- BApplying a restraint to prevent the client from getting up使用約束帶以防止病人起身
- CEncouraging regular vision and hearing exams✓ 正解鼓勵定期進行視力和聽力檢查
- DPlacing the call light within easy reach✓ 正解將呼叫鈴放置在容易觸及之處
- ERemoving clutter from the room✓ 正解清除房間內的雜物
— Explanation · 中文詳解 —
跌倒預防強調環境移除障礙（Clutter）、降低重心（Low position）、輔助工具即時可取（Call light）。束縛（Restraint）是極端手段，應盡量避免，不屬於常規防跌介入。定期檢查感官功能（視力、聽力）能從生理根源減少跌倒。
Include interventions such as keeping the bed in the lowest position, encouraging regular vision and hearing exams, placing the call light within easy reach, and removing clutter from the room. Restraints should be avoided as they increase injury risk and are not a standard fall prevention measure.
✦ 台美臨床差異
美國醫學界對約束使用（Physical Restraints）有嚴格的限制與法律要求，台灣亦隨病人自主權意識抬頭而趨於嚴謹。