護理師照護一位出現意識混亂的老年病人，優先採取行動為何？
A nurse is caring for an older adult client who is experiencing confusion. What is the nurse's priority action?
- AAdminister a PRN sedative to ensure the client stays calm給予處方用(PR N)鎮靜劑以確保個案保持平靜
- BPlace the client in a room near the nurses' station for constant observation將個案安置在護理站附近的房間以便持續觀察
- CRequest a chemical restraint order from the physician請求醫師開立化學性約束處方
- DOrient the client to the environment and assess for physiological causes✓ 正解引導個案定向環境並評估生理性原因
老年人意識混亂常為譫妄（Delirium）表現，背後多有急性生理因素（如感染、電解質失衡、缺氧）。優先採取安全 orient 環境措施並尋找生理病因是護理優先作為。C、A 為使用約束或鎮靜劑，屬於最後手段，非首選；B 雖為觀察手段，但優先順序低於病因評估。
Confusion in older adults is often a presentation of delirium, frequently caused by acute physiological factors (such as infection, electrolyte imbalance, or hypoxia). The nursing priorities are to provide a safe and orienting environment and to look for underlying physiological causes. Options C and A involve the use of restraints or sedatives, which are last-resort measures and not the first choice; option B, although an observational measure, is of lower priority than identifying the underlying cause.
美國對「限制身體自主權」有非常嚴格的法律訴訟風險；台灣亦重視，但對藥物使用評估較依賴醫師判斷。