護理師與一位個案互動時，個案開始出現攻擊行為並大聲咆哮。護理師應優先採取什麼行動？
A nurse is interacting with a client who begins to exhibit aggressive behavior and raises their voice. Which action should the nurse prioritize?
- AMaintain a safe distance and assess the situation for potential danger✓ 正解維持安全距離並評估情況中的潛在危險
- BAsk the client why they are angry to address the underlying issue詢問客戶為何生氣以解決根本問題
- CCall security immediately before attempting to de-escalate在嘗試減緩緊張局勢之前立即呼叫保全
- DEstablish a firm boundary and order the client to stop建立堅定的界線並命令客戶停止
面對具攻擊性的個案，護理師的臨床優先順序（Priority）永遠是安全（Safety）。第一步必須是評估環境風險並與個案保持安全距離（Safe distance），這能防止護理師受傷並給予個案空間。直接指令或過度刺激只會升高衝突，應在確保自身安全且有足夠支援的情況下，再採取去升級（De-escalation）技巧。若情況失控，應立即啟動機構的暴力通報程序，而非單打獨鬥。
When facing an aggressive client, the nurse's clinical priority is always safety. The first step must be to assess environmental risks and maintain a safe distance from the client; this prevents the nurse from being injured and gives the client space. Direct commands or excessive stimulation will only escalate the conflict, so de-escalation techniques should be applied only after personal safety is ensured and adequate support is available. If the situation gets out of control, the institution's violence-reporting protocol should be activated immediately rather than the nurse attempting to handle it alone.
美國臨床機構對於暴力預防非常嚴格，通常設有「Code Gray」等機制。護理師在美執業時，應熟記單位內啟動安全警報的方法，且絕對不建議在未有支援下單獨面對暴力病人。