護理師為病人執行身體約束時，下列哪項行動是強制性的？
When applying restraints to a client, which action is mandatory for the nurse?
- AObtain a physician's order within the facility's specific timeframe✓ 正解在機構規定的特定時間內取得醫師醫囑
- BCheck the client’s circulation every 2 hours每 2 小時檢查病人的循環狀況
- CEnsure the restraint is tied to the side rail確保約束帶綁在護欄上
- DApply restraints as a first-line intervention for agitation將約束作為躁動的第一線介入措施
身體約束（Restraints）屬於限制病人自主權的極端手段，必須嚴格遵守法律與機構政策（Facility policy）。護理師必須在評估病人有傷害自己或他人之虞後，由醫師開立正式醫囑（Physician's order），且需有時效限制（如 24 小時內需重新評估）。約束必須固定於床架（Bed frame），而非移動式的護欄（Side rail）。
Physical restraints are an extreme measure that restricts the client's autonomy and must strictly comply with law and facility policy. The nurse must, after determining that the client poses a risk of harm to self or others, obtain a formal physician's order, which must also be time-limited (for example, reassessed within 24 hours). Restraints must be secured to the bed frame, not to movable side rails.
在美國，使用約束的標準流程非常嚴格，需詳細記錄「嘗試過的其他非約束性替代方案（Alternative measures）」，例如陪伴、改變環境、調整藥物等。若無嘗試過替代方案，單純使用約束易面臨法律爭議。