護理師照護一位有跌倒史且意識混亂的病人。應優先採取哪項措施？
A nurse is caring for a client with a history of falls who is confused. Which intervention should the nurse implement first?
- AKeep all four side rails in the upright position將所有四個床欄保持在立起位置
- BRequest a prescription for a sedative申請鎮靜劑處方
- CMove the client to a room near the nurse's station✓ 正解將病人移至護理站附近的房間
- DApply soft wrist restraints使用軟式手腕約束
照護有跌倒史且意識混亂的病人，護理師的首要任務是確保其安全，同時應遵循「最少限制原則」（Least Restrictive Measures）。這意味著應優先採用非藥物、非身體約束的方式來管理病人的行為和確保安全，只有在所有溫和措施都無效且病人對自身或他人構成立即危險時，才考慮使用約束。將病人移至護理站附近的房間，能讓護理人員更容易且更頻繁地觀察病人，及早發現其意圖下床或出現危險行為，從而及時介入，有效預防跌倒，而無需依賴約束或鎮靜劑。
For a confused client with a history of falls, the nurse should prioritize the least restrictive safety measure, which is moving the client to a room near the nurse's station for increased observation. This allows for timely intervention if the client attempts to get out of bed without resorting to physical restraints or sedatives, which can worsen confusion and increase fall risk.
美國法規將「四支床欄」視為约束；台灣部分醫院臨床上仍普遍視其為安全措施，需注意國考定義。