精神科住院病人出現行為升級與口頭敵意。護理師應採取哪些措施以確保安全？（選所有適合的）
A client in the inpatient psychiatric unit is demonstrating escalating aggressive behavior and verbal hostility. Which nursing actions are appropriate to ensure safety? (Select all that apply.)
- AMaintain a safe physical distance from the client✓ 正解與病人保持安全的物理距離
- BUse clear, concise, and non-threatening communication✓ 正解使用清晰、簡潔且無威脅性的溝通方式
- CImmediately place the client in a seclusion room立即將病人安置於隔離室
- DEnsure an exit path is available for the staff✓ 正解確保護理人員有逃生路線
- ECall for additional staff support if needed✓ 正解如有需要，請求額外的人力支援
在精神科護理中，面對攻擊性行為，護理師的首要原則是確保自我與其他病人的安全（Safety first）。應遵循「去升級化」（De-escalation）原則，保持距離、使用非威脅性語言，並確保環境中有明確的撤離通道（Exit path），避免在封閉空間內與病人發生肢體衝突。若情況失控，應立即呼叫團隊支援（Team approach）。
In psychiatric nursing, the first principle when confronting aggressive behavior is to ensure safety for oneself and other clients. The nurse should follow de-escalation principles, maintain distance, use non-threatening language, and ensure there is a clear exit path, avoiding physical confrontation in a confined space. If the situation cannot be controlled, the nurse should immediately call for team support.