護理師照顧一位對他人表現出肢體攻擊行為的病人。下列哪項介入是優先處理？
A nurse is caring for a patient who is physically aggressive toward others. What is the priority intervention?
- ACall for assistance immediately and remove others from the area✓ 正解立即請求協助並將其他人移出該區域
- BUse physical restraints to protect the staff使用身體約束來保護員工
- CAttempt to verbally de-escalate the situation while remaining close在保持近距離的同時嘗試以言語緩和局勢
- DAdminister an emergency IM sedative medication給予緊急肌肉注射鎮靜藥物
面對具攻擊性的病人，護理師的首要原則永遠是「安全（Safety First）」。在 NCLEX 考試中，處理暴力事件的邏輯優先順序為：確保他人安全（病人、訪客、同事）→ 確保自身安全 → 嘗試去升級（De-escalation）→ 最後才是物理性約束或給予鎮靜劑。選項 A 透過移除他人來降低潛在傷害範圍，是保護環境安全最即時的措施。
When dealing with an aggressive client, the nurse's first principle is always "safety first." In NCLEX-style reasoning, the priority sequence for managing a violent incident is: ensure the safety of others (clients, visitors, colleagues), then ensure personal safety, then attempt de-escalation, and only finally use physical restraints or sedative medication. Option A, by removing other people from the area, immediately reduces the potential scope of harm and is the most timely measure to safeguard the environment.
美國醫院對暴力事件（Code Gray）有極嚴格的團隊介入流程，強調「不要單獨處理」；台灣臨床雖也有保全支援，但護理師常需第一線面對，需特別留意 NCLEX 強調「Call for assistance」的團隊合作概念。