護理師正在審查一位高跌倒風險病人的護理計畫，應包含哪些處置？（選所有適合的）
The nurse is reviewing the plan of care for a client at high risk for falls. Which interventions should the nurse include? (Select all that apply.)
- AKeep the bed in the lowest position with wheels locked✓ 正解將床降至最低位置並鎖住輪子
- BPlace the bedside commode close to the bed✓ 正解將床邊馬桶放置在床邊附近
- CKeep all four side rails in the upright position將四支床欄全部拉起
- DEnsure the call light is within reach at all times✓ 正解確保呼叫鈴隨時可在觸及範圍內
- EApply non-skid socks for the client when ambulating✓ 正解病人下床活動時穿著止滑襪
跌倒預防的核心在於環境安全與病人賦權。A（床高度最低、輪子鎖定）與 D（呼叫鈴隨手可及）是基礎安全環境，確保病人需要協助時能立即求援，且上下床高度安全。B（床邊活動馬桶）減少病人夜間奔走廁所的距離，降低走動中的風險。E（止滑襪）則是提供基礎的行走摩擦力。C（四支床欄全拉起）在護理專業中被視為『約束』（Restraint），反而可能增加病人跨越床欄跌下所造成的嚴重傷亡，因此錯誤。整體思路應放在減少障礙物、增加穩定性，並避免不當的身體限制。
Keeping the bed in the lowest position with wheels locked minimizes fall height and prevents bed movement. Placing a bedside commode nearby reduces the distance the client must travel, lowering fall risk during urgency. Ensuring the call light is within reach allows immediate assistance, and non-skid socks provide traction. Raising all four side rails is considered a restraint and increases injury risk.
美國醫院對於『側欄即約束』的法律定義極其嚴格，若無醫囑拉起四支欄杆會面臨法律責任與評鑑懲處。台灣雖然也推廣此概念，但實務上家屬有時會因擔心病人掉下床而要求全拉，護理師需投入更多溝通成本解釋約束的風險。