護理師照護一位正發生暴力行為的病人，優先措施為何？
A nurse is caring for a client who is experiencing a violent outburst. What is the priority nursing action?
- AAdminister an PRN sedative medication給予備用鎮定劑
- BAttempt to calm the client verbally嘗試以言語安撫病人
- CEnsure the safety of the client and others✓ 正解確保病人及他人的安全
- DCall security to restrain the client呼叫保全人員約束病人
在面對暴力行為（Violent outburst）時，NCLEX 的首要原則永遠是「安全」（Safety）。護理師必須先確保自己、其他病人以及該病人的安全。若環境中存在危險物品，應立即移除或將病人移至安全區域。在安全未獲得保障前，任何溝通或藥物介入皆無法有效執行，這是 ABC 與安全優先原則的體現。
When confronting a violent outburst, the foremost NCLEX principle is always safety. The nurse must first ensure the safety of the nurse, other patients, and the patient themselves. If dangerous objects are present in the environment, they must be removed immediately, or the patient must be moved to a safe area. Until safety has been secured, no communication or pharmacologic intervention can be effectively carried out; this reflects the ABC and safety-first principle.
美國醫院對暴力行為的處理流程（Code Grey 或相關代號）非常嚴謹，護理師在面對威脅時，優先權限是撤離並呼叫團隊（Security/Psychiatric Response Team），這與台灣部分臨床情境中護理師仍試圖獨自安撫的習慣有顯著差異。