一位精神科住院病人出現來回踱步、緊握拳頭並對醫護大吼。下列何項為最優先的處置？
A client in a psychiatric unit begins pacing, clenching fists, and shouting at staff. Which initial intervention is most appropriate?
- AMaintain a safe distance and speak in a calm, low voice✓ 正解保持安全距離並以平靜、低沉的語調說話
- BAdminister an as-needed dose of lorazepam給予處方之 lorazepam 按需劑量
- CCall for security personnel to surround the client呼叫保全人員包圍病人
- DPlace the client in physical restraints immediately立即對病人實施身體約束
面對出現激動、踱步與攻擊徵兆（Agitated behavior）的病人，護理師的首要目標是去激化（De-escalation）情境並確保環境安全。採取非威脅性的溝通方式，能降低病人的防衛心與焦慮，避免衝突升級。根據 NCLEX 的安全優先原則，應先嘗試非侵入性的溝通介入，而非立即動用限制行動（Restraints）或武力，因為這些措施僅在病人對自己或他人造成立即性身體威脅且口語溝通無效時作為最後手段（Last resort）。
When facing a client exhibiting agitated behavior such as pacing and signs of imminent aggression, the nurse's primary goal is de-escalation and ensuring environmental safety. Using a non-threatening communication style reduces the client's defensiveness and anxiety and prevents escalation. According to the NCLEX priority of safety, the nurse should first attempt non-invasive communication strategies rather than immediately use restraints or force, which should be reserved as a last resort when the client poses an immediate physical threat to self or others and verbal communication has failed.
在美國精神科病房，去激化（De-escalation）技巧是被高度訓練的標準流程，護理師需展現自信但非威脅的肢體語言。台灣臨床有時較依賴警衛介入，但在 NCLEX 中，必須強調護理師自身具備的溝通技巧與空間控制能力。