— 安全與感染控制 · MEDIUM · SATA —
一位跌倒高危險群病人，護理師應包含哪些護理措施？（選所有適合的）
A client is at high risk for falls. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床調整至最低位置
- BEncourage the use of nonskid footwear✓ 正解鼓勵穿著防滑鞋
- CPlace the call light within reach✓ 正解將呼叫鈴放置在病人可及之處
- DApply physical restraints to keep the patient in bed使用身體約束具以防止病人離床
- EMaintain adequate lighting in the room✓ 正解維持室內充足照明
— Explanation · 中文詳解 —
預防跌倒的基礎在於環境改善與病人行為引導。降低床位可減少跌倒高度，止滑鞋與充足照明能增加安全性，呼叫鈴則可確保病人需協助時能即時聯繫。身體約束屬於最後手段，僅在病人有傷害自己或他人風險且所有替代方案無效後，經醫師評估才可使用，不得為了預防跌倒而作為常規選項。
Fall prevention interventions include keeping the bed in the lowest position to minimize injury height, encouraging nonskid footwear for better traction, placing the call light within reach for immediate assistance, and maintaining adequate lighting to prevent tripping. Physical restraints are not a standard precaution for falls and should only be used as a last resort when other measures fail.
✦ 台美臨床差異
美國非常強調約束（Restraint）的法律規範與替代方案；台灣則在評鑑要求下對約束使用趨於嚴謹，但臨床執行仍常因人力不足而過度使用。