— 照護管理 · MEDIUM · SATA —
護理師照顧一位有跌倒病史的病人。哪些跌倒預防措施是適當的？（選所有適合的）
A nurse is caring for a client with a history of falls. Which measures are appropriate for fall prevention? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將床置於最低位置
- BPlace the call light within reach✓ 正解將呼叫鈴放置在觸手可及處
- CEncourage the client to use a walker✓ 正解鼓勵病人使用助行器
- DKeep the floor free of clutter✓ 正解保持地面無雜物
- EApply soft restraints to prevent the client from getting up使用軟性約束帶以防止病人起身
— Explanation · 中文詳解 —
跌倒預防策略：環境安全與輔助工具使用。A, B, C, D 均為標準且有效的跌倒預防措施。E 錯誤：約束（Restraints）是限制人身自由的最後手段，不得僅因為預防跌倒就擅自使用，必須符合醫囑且有嚴格適應症，否則構成違法限制自由。
Appropriate fall prevention measures include keeping the bed in the lowest position, placing the call light within reach, encouraging the use of assistive devices like walkers, and keeping the floor free of clutter. Soft restraints should not be used solely for fall prevention as they are a last resort requiring specific orders and can increase injury risk.
✦ 台美臨床差異
美國法規對使用約束（Restraints）有極嚴格限制與記錄要求；台灣在某些病房型態中約束使用率較高，但目前亦正積極推動去約束化。