一位護理師照顧一位具有侵略性並威脅醫護人員的病人。下列哪項是最初的適當處理策略？
A nurse is caring for a client who is aggressive and threatens staff. Which is the most appropriate initial management strategy?
- AMaintain a safe distance and call for assistance✓ 正解保持安全距離並請求協助
- BAdminister an as-needed sedative medication給予按需鎮靜藥物
- CConfront the client to set clear behavioral boundaries與案主對峙以設定明確的行為界線
- DImmediately restrain the client to ensure safety立即約束案主以確保安全
面對具侵略性或威脅行為的病人，護理師的首要任務是確保自身及他人的安全。臨床處理原則遵循「最小限制原則（Least Restrictive Environment）」，即在暴力尚未發生或升級前，應先採取去升級（De-escalation）技巧。保持安全距離並呼叫支援是保護自己的第一線措施，能有效預防肢體衝突。約束（Restraint）屬於最後手段，必須有明確臨床依據且在其他方法無效後方可執行。直接對抗或強行給藥容易激化病人情緒，增加暴力風險。
When facing a client who is aggressive or threatening, the nurse's first priority is to ensure personal and others' safety. Clinical management follows the principle of the Least Restrictive Environment, meaning that de-escalation techniques should be employed before violence occurs or escalates. Maintaining a safe distance and calling for assistance is the front-line measure to protect oneself and effectively prevent physical confrontation. Restraint is a last resort and may be performed only when there is clear clinical justification and other methods have failed. Direct confrontation or forced medication tends to escalate the client's emotions and increase the risk of violence.
美國醫院對暴力管理極為嚴格，通常設有「Code Grey」或類似機制，要求護理師在遇到威脅時立即啟動團隊支援，而非單獨處理。台灣臨床相對較少使用專門的暴力代碼系統，護理師常需自行判斷或呼叫保全。