護理師發現一位有跌倒病史的病人正試圖下床。下列哪項措施最能確保病人安全？
A nurse notices a client with a history of falls attempting to get out of bed. Which intervention is most appropriate to ensure safety?
- AApply a vest restraint immediately立即使用背心式約束帶
- BAdminister a PRN sedative to keep the client calm給予處方用鎮靜劑以維持病人平靜
- CAsk the client to stay in bed and offer assistance✓ 正解請病人留在床上並提供協助
- DLower the bed to the lowest position and leave the side rails up將床降至最低位置並拉起側欄
跌倒預防的核心在於『最小限制（Least Restrictive Environment）』原則。當護理師發現病人試圖下床時，應優先進行臨床評估，了解病人行為背後的動機（如是否急需如廁、疼痛或感到焦慮）。直接採取約束或藥物干預會剝奪病人的自主權且增加併發症風險。透過溝通與協助，不僅能維護病人安全，也能建立治療性護理關係。
The least restrictive environment principle prioritizes assessing the client's needs, such as toileting or pain, before implementing safety measures. Directly applying restraints or sedatives deprives the client of autonomy and increases complication risks, whereas offering assistance maintains safety and supports a therapeutic relationship.
美國醫院非常重視『約束（Restraint）』的使用規範，必須嚴格遵守『非約束性替代方案（Non-restraint alternatives）』優先的原則。在台灣臨床環境中，有時約束的使用較為寬鬆，但 NCLEX 考試中必須嚴守美國 Joint Commission 的約束規範。