護理師在外科病房遇到一位對工作人員大聲叫囂並威脅的病人，請問優先護理措施為何？
A nurse is working on a medical-surgical unit and encounters a client who is shouting and threatening staff. What is the priority nursing action?
- AAdminister an emergency sedative給予緊急鎮靜劑
- BCall hospital security for assistance呼叫醫院保全協助
- CAttempt to de-escalate the situation verbally嘗試以言語降低局勢緊張
- DRemove other clients from the area✓ 正解將其他病患帶離該區域
面對暴力威脅的病人，護理師的首要原則是「環境安全（Safety First）」。依據 NCLEX 的優先順序原則，在處理攻擊者之前，必須先保護其他無辜病人免受傷害。將其他病人移開不僅能減少潛在受害者，也能降低攻擊者的刺激源，創造較為冷靜的環境。隨後才進行語言冷靜（De-escalation）、尋求人力支援（Security）或依醫囑給予藥物控制。
When facing a patient who poses a threat of violence, the nurse's primary principle is "safety first." According to NCLEX prioritization principles, other innocent patients must first be protected from harm before the aggressor is dealt with. Moving the other patients away not only reduces potential victims but also decreases stimuli for the aggressor and creates a calmer environment. Verbal de-escalation, calling for additional staff or security, and administering prescribed medications follow thereafter.
美國醫院對於暴力事件有嚴格的 Code Grey (或類似代號) 政策，護理師受過專業的 Crisis Prevention Institute (CPI) 訓練，強調在動用保安前先移除病人的刺激源，並維持自身安全距離。