住院病房的一位病人變得越來越躁動並開始在走廊踱步。護理師應首先採取哪項行動？
A client on the inpatient unit is becoming increasingly agitated and begins pacing the hallway. Which action should the nurse take first?
- AApproach the client in a calm, non-threatening manner✓ 正解以平靜、非威脅性的方式接近病人
- BCall for a 'code green' or security assistance呼叫 'code green' 或尋求保全協助
- CDirect the client to go back to their room and stay there指示病人回到房間並待在那裡
- DAdminister a PRN sedative medication immediately立即給予處方備用（PRN）鎮靜藥物
對於開始躁動的病人，首選介入措施是使用去激化（De-escalation）技巧。以冷靜、非威脅性的方式接近病人，可以幫助評估病人的需求並嘗試口頭緩解焦慮。過早使用藥物（D）或呼叫保全（B）可能會讓病人感到受威脅而加劇攻擊性。命令式口氣（C）容易引發病人的反抗心理。
For a client beginning to escalate, the intervention of choice is the use of de-escalation techniques. Approaching the client in a calm, nonthreatening manner allows the nurse to assess the client's needs and attempt to verbally alleviate the anxiety. Administering medication too early (D) or calling security (B) can make the client feel threatened and intensify aggression. A commanding tone (C) easily provokes resistance in the client.
美國強調「Least Restrictive Environment」（最少限制環境）；台灣臨床雖也推行，但在人力不足時，可能會較快動用團隊介入以防意外。