— 安全與感染控制 · HARD · MCQ —
病人因暴力行為被安置於保護室。護理師應優先採取的措施為何？
A client is in seclusion due to violent behavior. Which nursing action is priority?
- AProvide meals every 8 hours每8小時提供餐點
- BEnsure the client has access to a bathroom確保病人有廁所可使用
- CContinuously monitor via camera or in-person✓ 正解透過攝影機或親自持續監測
- DAssess the client every 4 hours每4小時評估病人
— Explanation · 中文詳解 —
被安置於保護室（Seclusion）的病人通常處於極度激動或暴力狀態，存在高度自傷或傷人風險。根據法律與安全規範，護理師必須進行「持續監測（Continuous monitoring）」，透過攝影機或專人親自觀察，確保病人生命徵象穩定、有無受傷或呼吸道受阻。定時查房（如每 4 小時）不足以應對突發性的行為改變或生理窘迫。
A client placed in seclusion is typically extremely agitated or violent and is at high risk of self-harm or harm to others. According to legal and safety standards, the nurse must maintain continuous monitoring via camera or in-person observation to ensure that vital signs are stable and that the client is free of injury or airway compromise. Scheduled rounds (for example, every 4 hours) are insufficient to respond to sudden changes in behavior or physiological distress.