— 基本照護與舒適 · MEDIUM · SATA —
護理師照護一位有跌倒病史的病人。下列哪些安全措施有助於預防跌倒？（選所有適合的）
A nurse is managing a client with a history of falls. Which safety measures should be implemented to prevent further falls? (Select all that apply.)
- AKeep the call light within the client's reach✓ 正解將呼叫器置於病人可及之處
- BPlace the client in a room near the nursing station✓ 正解將病人安置在護理站附近的房間
- CMaintain the bed in the lowest position✓ 正解保持病床處於最低位置
- DUse physical restraints for all patients with fall history對所有有跌倒史的病患使用身體約束
- EEnsure the floor is free of clutter✓ 正解確保地面無雜物
— Explanation · 中文詳解 —
防跌措施的核心在於環境與提醒。呼叫鈴在手可讓病人主動求助；近護理站便於密切監測；低床位可減小跌倒高度；移除雜物消除環境障礙。限制身體約束屬最後手段，僅在嚴重認知障礙並危及安全時使用，不可針對所有跌倒高風險者。
Effective fall prevention includes keeping the call light within reach, placing the client near the nursing station for frequent observation, maintaining the bed in the lowest position, and ensuring the floor is free of clutter. Physical restraints should not be used routinely as they can increase confusion and injury risk.
✦ 台美臨床差異
美台皆強調防跌措施，但在美國，身體約束（Restraint）的審核機制較台灣更為嚴謹與結構化。