護理師照護一位正使用手腕約束的病人。下列哪項評估結果需要護理師『立即』介入？
A nurse is caring for a client who is in wrist restraints. Which assessment finding requires immediate intervention by the nurse?
- AThe restraint is tied to the side rail of the bed✓ 正解約束帶綁在床欄側邊
- BThe client's family expresses concern about the restraints病人家屬對約束帶表示擔憂
- CThe nurse can fit two fingers between the restraint and the wrist護理師可在約束帶與手腕間放入兩指
- DThe restraint order was renewed 12 hours ago約束醫囑於 12 小时前續開
約束具的使用安全性是本題重點。B（綁在床欄）是嚴重的安全隱患，因為當床欄降下或調整床頭高度時，可能會過度拉扯病人的肢體，造成骨折或神經損傷。正確做法應綁在『床架』（Bed frame）的不動部分。為什麼其他選項不是最優先？A（家屬擔心）需要衛教但無立即危險；C（兩指寬）是正確的緊密度標準；D（12 小時前續開醫囑）在成人非暴力行為約束中通常是每 24 小時續開一次（視機構規定，有時是 4 小時），若無臨床惡化，A 的物理風險更高。這題考驗的是對潛在致命風險的識別。
The focus of this question is the safety of restraint use. Option A (tied to the side rail) is a serious safety hazard, because when the side rail is lowered or the head of the bed is adjusted, the patient's limb may be pulled excessively, leading to fracture or nerve injury. The correct practice is to tie the restraint to a non-moving part of the bed frame. Why are the other options not the highest priority? A (family concern) requires education but poses no immediate danger; C (two-finger width) is the correct standard for tightness; D (restraint order renewed 12 hours ago) is typically renewed every 24 hours in adult non-violent restraint use (depending on institutional policy, sometimes every 4 hours), and without clinical deterioration, the physical risk posed by A is greater. This question tests the recognition of potentially lethal risks.
美國 Joint Commission 對約束安全有極其細膩的稽核（如必須使用快速解開結 Quick-release knot）；台灣雖然也有約束指引，但在臨床忙碌時，綁在床欄的錯誤行為偶爾可見，需加強教育。