— 基本照護與舒適 · MEDIUM · MCQ —
護理師協助一位早期失智症病人沐浴時，病人變得煩躁並試圖攻擊護理師。此時護理師的優先處置為何？
A nurse is assisting a client with early-stage dementia during a bath. The client becomes agitated and tries to hit the nurse. What is the priority nursing action?
- AFirmly tell the client that hitting is unacceptable堅定地告訴病人打人是不被接受的
- BCall for assistance to restrain the client呼叫協助以約束病人
- CStop the bathing and allow the client to calm down✓ 正解停止沐浴並讓病人冷靜下來
- DContinue the bath to complete the hygiene task繼續沐浴以完成衛生任務
— Explanation · 中文詳解 —
失智症病人常因認知功能障礙（Cognitive impairment）導致對環境刺激產生混亂，進而引發戰鬥或逃跑反應（Fight or flight）。沐浴對病人而言可能是過度刺激的過程。優先處置應是『減輕壓力源』，暫停操作以維護病人與護理師的安全。這體現了『以病人為中心』的護理照護，避免強迫行為導致衝突升級。
Clients with dementia often respond to environmental stimuli with confusion because of cognitive impairment, triggering a fight-or-flight response. Bathing may be overstimulating for the client. The priority intervention is to reduce the stressor by stopping the activity to protect both the client and the nurse. This reflects patient-centered care and avoids escalating the conflict through forced behavior.