— 基本照護與舒適 · MEDIUM · MCQ —
護理師協助一位初期失智症且出現躁動的病人。下列哪項初始護理方式最好？
A nurse is assisting a client with early stage dementia who is becoming agitated. What is the best initial nursing approach?
- AInform the client's family of the behavior告知病人家屬該行為
- BSpeak firmly to stop the agitation堅定地說話以制止躁動
- CUse a calm, quiet tone and redirect the client✓ 正解使用平靜、安靜的語調並轉移病人注意力
- DRestrain the client to ensure safety約束病人以確保安全
— Explanation · 中文詳解 —
對於失智症躁動，應優先使用非藥物、非限制性手段。穩定、安靜的語氣有助於緩和病人情緒，轉移注意力（Redirection）是標準的護理技巧。約束會加重焦慮；嚴厲語氣會激起對抗；通知家人並非第一時間需做的臨床緊急處置。
For agitation in early dementia, first-line management is non-pharmacologic and non-restrictive. A calm, quiet tone and redirection to a soothing activity or topic reduces stimulation and de-escalates without confrontation. Restraints worsen agitation and confusion, firm/harsh tones provoke resistance, and notifying the family is not an immediate clinical intervention.
✦ 台美臨床差異
美國非常強調「去約束」（Restraint-free）政策，台灣在長照環境下也推動，但臨床人力不足時執行困難。