護理師正在收納一位正經歷躁症發作的雙極性情感障礙病人。病人聲音洪亮、態度強勢且來回踱步。最恰當的初步護理行動是什麼？
A nurse is admitting a client with bipolar disorder experiencing a manic episode. The client is loud, demanding, and pacing. What is the most appropriate initial nursing action?
- AAdminister restraints immediately due to agitation.因躁動立即給予約束。
- BEngage the client in a lengthy discussion about their feelings.與患者進行關於其感受的長時間討論。
- CProvide a low-stimulation environment and set limits calmly.✓ 正解提供低刺激環境並冷靜設定界限。
- DEncourage the client to sit down and rest.鼓勵患者坐下休息。
躁症（Manic episode）病人常處於高度激動、易怒狀態。護理的核心目標是維持病人與環境的安全，並減少過度刺激（Environmental stimulation）。過多的感官輸入會加劇病人的躁動。採取冷靜、堅定且簡潔的界線（Limits）能提供結構感，幫助病人掌控衝動行為，並展現護理師的專業掌控力，而非情緒化反應。
Clients in a manic episode are often highly agitated and irritable. The core nursing goal is to maintain client and environmental safety and to reduce excessive environmental stimulation. Too much sensory input worsens the client's agitation. Calm, firm, and concise limit-setting provides structure, helps the client regain control over impulsive behavior, and demonstrates the nurse's professional composure rather than emotional reactivity.
在美國臨床環境中，針對躁動病人使用約束（Physical Restraints）有極嚴格的法律規範（CMS regulations），必須先嘗試所有替代方案（如藥物、環境調整、一對一陪伴）無效後才可執行，且需頻繁評估與快速移除。