護理師照護具暴力潛傾向的個案時，應採取哪些措施？（選所有適合的）
Which of the following actions should the nurse take when caring for a client who is exhibiting signs of potential physical violence? (Select all that apply.)
- AMaintain a distance of at least two arm lengths from the client✓ 正解與病人保持至少兩臂長之距離
- BEnsure the nurse has a clear path to the exit✓ 正解確保護理師有清晰之逃生路線
- CKeep hands visible and avoid sudden movements✓ 正解保持雙手可見並避免突然動作
- DChallenge the client's hostile statements to establish boundaries挑戰病人具敵意的陳述以建立界線
- EPlace the client in a room with minimal furniture✓ 正解將病人安置於傢俱最少之房間
處理暴力傾向個案時，安全為第一考量。保持適當距離可避免受襲，確保逃生路徑可避免受困，手部可見能傳達無威脅訊號。移除環境中的硬物或家具可減少衝突升級時的武器風險。挑戰個案言論反而可能誘發攻擊，應以非對抗性態度處理。
When managing a client with potential violence, safety is the foremost concern. Maintaining an appropriate distance prevents being struck, ensuring an escape route avoids becoming trapped, and keeping hands visible signals non-threat. Removing hard objects or furniture from the environment minimizes the risk of items being used as weapons during escalation. Confronting the client's statements may instead provoke attack and should be replaced with a non-adversarial approach.
台灣醫院通常備有警衛系統（Code White），美國護理師則更強調去升級溝通（De-escalation）。