對於使用手腕約束的病人，哪項評估是最高優先級？
Which assessment is the highest priority for a client in wrist restraints?
- APresence of a radial pulse and finger sensation✓ 正解橈動脈搏動與手指感覺的存在與否
- BRange of motion in the shoulders肩膀的活動範圍
- CClient's orientation to person, place, and time病人對人、時、地的定向力
- DClient's ability to perform self-care病人執行自我照護的能力
對於使用手腕約束（wrist restraints）的病人，護理師的首要任務是確保約束裝置未對病人的肢體造成傷害，特別是神經血管功能。約束帶施加的壓力可能壓迫到供應肢體的動脈和神經，導致血液循環障礙或神經損傷。這可能迅速進展為肢體缺血、壞死或永久性神經功能受損。因此，評估橈動脈搏動（radial pulse）和手指感覺（finger sensation）是最高優先級的護理措施，因為這直接關係到肢體的完整性和功能。此評估屬於「循環 (Circulation)」範疇，是 ABC 優先原則中的關鍵環節，確保病人的生理安全。
For a client in wrist restraints, the nurse's priority is to ensure the device does not injure the limb, particularly its neurovascular function. Restraint pressure may compress the artery and nerve supplying the hand, leading to ischemia or nerve injury that can progress to limb ischemia, necrosis, or permanent neurologic damage. Therefore, assessing the radial pulse and finger sensation is the highest priority because it directly safeguards limb integrity and function. This falls under 'Circulation' in the ABC priority framework, ensuring physiologic safety.
美國法規對約束之紀錄要求細緻到每一分鐘的觀察；台灣相對較強調定時巡房紀錄。