護理師照護一位意識混亂且反覆嘗試下床的老年病人。為確保病人安全，護理師應首先採取哪項干預措施？
A nurse is caring for an older adult client who is confused and repeatedly tries to get out of bed. Which intervention should the nurse implement first to ensure client safety?
- AApply soft wrist restraints to prevent the client from falling.施加軟式手腕約束帶以防止病患跌倒
- BMove the client to a room closer to the nurses' station.✓ 正解將病患移至靠近護理站房間
- CRequest a family member to stay with the client around the clock.要求家屬全天候陪伴病患
- DObtain a prescription for a sedative medication.取得鎮靜劑處方
本題探討的是『約束最小化』與安全優先原則。對於有跌倒風險且混亂的病人，首選應是非侵入性且能增加監督強度的措施。將病人移至靠近護理站的房間（選項 B）能讓護理人員更頻繁地觀察病人，及時介入其危險行為，這是最符合倫理且優先的行動。選項 A 的約束（Restraints）應是所有措施無效後的最後手段，且需要醫師處方與嚴格監測。選項 D 使用鎮靜劑（Chemical restraint）會增加老年人瞻妄與跌倒的風險，不應作為首選。選項 C 雖然有助於安全，但安排家屬是外部資源，護理師應先從護理系統內部的調整做起。臨床思路上，護理師應優先考慮環境調整、增加觀察頻率與病人需求評估（如是否需要如廁），以減少對強制手段的依賴，這體現了對病人尊嚴的尊重與管理的高效性。
This item addresses the principles of "least restraint" and prioritizing safety. For a patient who is at risk of falling and confused, the first choice should be a noninvasive measure that increases supervision. Moving the patient to a room near the nursing station (option B) allows the nursing staff to observe the patient more frequently and intervene promptly in unsafe behavior; it is the most ethical and priority action. Restraints (option A) should be the last resort, used only after all other measures have failed, and require a physician's order and rigorous monitoring. Use of sedatives (chemical restraint, option D) increases the risk of delirium and falls in older adults and should not be a first choice. Option C may help with safety, but family-provided supervision is an external resource; the nurse should first make adjustments within the nursing system. Clinically, the nurse should prioritize environmental modification, increased observation frequency, and assessment of patient needs (such as the need to use the bathroom) to reduce reliance on coercive measures, which reflects respect for the patient's dignity and management efficiency.
美國醫院對「零約束（Restraint-Free）」有極高要求，使用約束需每 2 小時評估並頻繁更新醫囑；台灣雖也推行減少約束，但在人力資源吃緊的情況下，對於高風險病人，家屬聘請看護（Sitter）或使用約束的門檻有時相對較低，但護理標準仍一致強調優先環境介入。