一位病人表現出暴力傾向，護理師的首要行動為何？

Core concept: When a patient exhibits violent behavior, safety is the primary consideration. This includes the safety of the patient, staff, and other patients. The nurse must assess and ensure personal safety before taking any intervention. Why the correct answer is right: Option D states 'Ensure the nurse has an unobstructed path to the exit,' which is the highest-priority safety measure. In a potentially violent situation, the nurse must first assess the environment to ensure that they cannot be trapped and can withdraw safely at any time. This is based on the principle of 'safety first,' which takes priority over any other intervention. Why the other options are wrong: Options A (calling security) and C (verbal de-escalation) are important strategies but must be carried out only after the nurse's own safety has been ensured. If the nurse is in danger, the first step is to ensure the ability to escape, then seek help or attempt communication. Option A (administering a sedative) requires a provider's order and is generally considered only when the patient has been assessed as severely agitated and poses immediate danger and when non-pharmacologic interventions have failed; this is not the priority action, and the administration process must also be performed safely. Clinical reasoning (Priority / Safety / ABC): Decision making here follows the highest principle of 'safety.' In emergency or potentially dangerous situations, the nurse's first task is to protect themselves from harm. Once personal safety is secured, subsequent assessment and interventions — calling for assistance, attempting verbal de-escalation, or administering medication if needed — can be performed effectively.