護理師照護一位意識混亂的老年病人，該病人反覆嘗試拔除靜脈輸液管。護理師應優先實施哪項措施？
A nurse is caring for an older adult client who is confused and repeatedly tries to pull out their IV line. Which intervention should the nurse implement first?
- AAsk a family member to sit with the client請家屬坐在客戶身邊
- BCover the IV site with a long-sleeved gown or stockinette✓ 正解用長袖衣服或彈性紗網覆蓋靜脈輸液部位
- CApply soft wrist restraints to both arms在雙臂上施加軟式手腕約束帶
- DAdminister a PRN dose of haloperidol給予 PRN 劑量的 haloperidol
在處理病人的干擾性行為（如拔除管路）時，護理干預應遵循『最少限制原則』（Least Restrictive Environment）。這題考的是優先次序。D（覆蓋 IV 處）是一種非限制性的環境調整，讓病人看不見管路，能有效減少拔管動機而不限制肢體活動。為什麼不選 C？物理約束是最後手段，必須有醫囑且其他方法無效才用。B（家屬陪同）雖然有效但非護理師可獨立完成的技術干預。C（藥物）屬於化學約束，同樣不是首選。臨床思路應為：環境調整 > 行為介入 > 物理/化學約束。
When managing a client's disruptive behavior (such as pulling out tubes), nursing interventions should follow the principle of the least restrictive environment. This question is about priorities. D (covering the IV site) is a non-restrictive environmental modification that keeps the line out of the client's sight, effectively reducing the urge to pull while not limiting physical activity. Why not A? Physical restraints are a last resort, requiring a provider's order and used only after other measures have failed. B (family member at bedside), although effective, is not a technical intervention the nurse can implement independently. C (medication) is a form of chemical restraint and likewise is not first-line. The clinical priority is: environmental modification > behavioral intervention > physical/chemical restraints.
美國法規對『約束』的定義與查核極其嚴格，護理師若未先嘗試非約束方法會面臨法律責任；台灣醫院雖然也強調減束，但在人力不足時，約束的使用門檻往往比美國低，這需在考照時特別調適觀念。