— 照護管理 · HARD · MCQ —
護理師照顧一位正處於暴力發作的病人，哪項措施應優先採取以維護安全？
A nurse is caring for a client who is experiencing a violent outburst. Which action should the nurse prioritize to maintain safety?
- AAttempt to reason with the client to de-escalate the situation嘗試與病人講道理以緩和局勢
- BAdminister an emergency sedative as ordered依醫囑給予緊急鎮靜劑
- CClear the area of other clients and call for assistance✓ 正解清場移除其他病人並請求協助
- DRestrain the client immediately to prevent injury立即約束病人以防止受傷
— Explanation · 中文詳解 —
暴力情境處理原則首重「環境與人員安全」。護理師應先移開無辜的第三者（病人、家屬）並召集足夠人力，在確保自身安全的前提下才考慮鎮靜或約束。過早靠近進行勸說（A）或使用約束（D）可能讓自己暴露於危險中，必須具備足夠人力支援才進行下一步。
The principle for managing a violent situation is "environmental and personnel safety first." The nurse should first remove uninvolved third parties (clients, family members) and assemble adequate personnel; only after ensuring personal safety should sedation or restraint be considered. Approaching too early to talk the client down (A) or applying restraints (D) prematurely may place the nurse at risk and must wait until sufficient staff are available.
✦ 台美臨床差異
美國法規對於約束（Restraints）的使用條件極嚴格，台美均強調暴力預防與團隊協作。