護理師照顧一位有跌倒病史的病人，應採取哪些措施以促進安全？（選所有適合的）
A nurse is managing a client with a history of falls. Which actions are appropriate to implement to promote safety? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床維持在最低位置
- BPlace the call light within the client's reach✓ 正解將呼叫鈴放置在病人可觸及之處
- CInstruct the client to call for assistance before getting up✓ 正解指導病人在起身前尋求協助
- DApply physical restraints to prevent the client from leaving the bed使用身體約束帶以防止病人離開床鋪
- EEnsure the room is well-lit at night✓ 正解確保夜間房間燈光明亮
預防跌倒的黃金原則是環境調適與教育。低床位、呼叫鈴在手邊、衛教病人求助及充足照明均能有效降低跌倒風險。物理約束（Restraints）屬於最後手段，僅在病人有傷害自己或他人之虞且其他方法無效時才使用，不能僅為了「預防跌倒」而隨意約束。
Fall prevention relies on environmental modifications and client education, such as keeping the bed in the lowest position, ensuring the call light is within reach, instructing the client to ask for assistance, and maintaining adequate lighting. Physical restraints are not a routine fall prevention strategy and should only be used as a last resort when there is an imminent risk of harm to self or others and other interventions have failed.
美國對使用約束（Restraints）的法律規範極嚴，必須符合「最小限制原則」；台灣臨床中約束使用率相對較高。