護理師照護一位受約束的病人。下列哪項護理措施具備最高優先級？
A nurse is caring for a client who is in restraints. Which of the following is the highest priority nursing action?
- ADocumentation of the client's behavior every 4 hours每4小時記錄病人行為
- BRe-evaluating the need for restraints every 15 minutes每15分鐘重新評估約束之必要性
- CAssessment of circulation and skin integrity every 2 hours✓ 正解每2小時評估循環與皮膚完整性
- DProviding adequate hydration and bathroom access every hour每小時提供充足的水分與如廁協助
約束（Restraints）屬於限制病人自主權的介入，必須嚴格遵守安全規範。約束最嚴重的併發症為神經血管受損與皮膚破損。根據護理安全原則，生理需求（Circulation, Sensory, Safety）高於記錄行政作業。護理師必須定期評估約束處遠端循環（脈搏、膚色、溫度、毛細血管充盈時間）及皮膚完整性，以防止不可逆的組織損傷。
Restraints limit autonomy and require strict safety adherence. The most serious complications are neurovascular compromise and skin breakdown. Per nursing safety principles, physiological needs (circulation, sensation, safety) take priority over administrative documentation. The nurse must regularly assess distal circulation (pulse, color, temperature, capillary refill) and skin integrity to prevent irreversible tissue damage.
美國法規對約束（Restraints）的規範極為嚴格，必須有醫師即時醫囑（通常 1 小時內補開），且護理師需嚴格執行週期性的循環評估與釋放練習（Range of Motion），違規可能導致機構面臨巨額罰款或撤照。