病人有約束（Restraint）醫囑，護理師首要行動為何？
A client has an order for a restraint. What is the priority nursing action?
- AApply the restraint as tightly as possible to ensure safety盡可能緊密地施加約束以確保安全
- BAssess the client’s skin and circulation every 2 hours每 2 小時評估個案的皮膚和循環狀況
- CExplain the need for restraint to the family向家屬解釋使用約束的必要性的
- DUse the least restrictive restraint possible✓ 正解使用限制最小的約束方式
約束（Restraint）的使用在美國護理實務中受到嚴格法律規範。護理師的首要任務是確保病人安全與尊嚴，根據倫理原則，必須優先考慮「限制最少化（Least restrictive）」。這意味著在採取約束之前，必須窮盡一切替代方案（如增加陪伴、調整環境、離床警報等）。若必須使用，則需有醫師醫囑，並嚴格執行定時評估。
The use of restraints is strictly regulated by law in U.S. nursing practice. The nurse's primary responsibility is to ensure patient safety and dignity, and ethical principles require that the 'least restrictive' option be considered first. This means that before applying a restraint, all alternatives (such as increased companionship, environmental modification, bed exit alarms, etc.) must be exhausted. If a restraint must be used, a physician's order is required and scheduled assessments must be strictly carried out.
美國對約束的規範（如 CMS 與 Joint Commission 標準）極為嚴格，必須有醫師即時醫囑（non-PRN order），且必須頻繁進行面對面評估。台灣臨床實務中，對於約束的執行與醫囑開立流程與美國高度一致，皆強調替代方案優先。