護理師照顧一位具攻擊行為且已使用軟式手腕約束的病人。護理師應優先採取哪項行動以確保法律與臨床安全？
A nurse is caring for a client with an aggressive behavior who is placed in soft wrist restraints. Which action should the nurse prioritize to ensure legal and clinical safety?
- ACheck the client's pulse and skin integrity every 2 hours每 2 小時檢查病人的脈搏和皮膚完整性
- BRelease the restraints every 2 hours for range-of-motion exercises✓ 正解每 2 小時解開約束帶以進行關節活動範圍運動
- CObtain a verbal order and have the physician sign it within 48 hours取得口頭醫囑並在 48 小時內請醫師簽署
- DEnsure the restraint is tied directly to the side rails for stability確保約束帶直接綁在床欄上以保持穩定
對於受到約束的病人，生理需求的滿足與併發症的預防是護理重點。雖然監測循環（A）很重要，但 NCLEX 的標準介入是每 2 小時必須「移除約束」一次，進行全關節活動（ROM）、評估皮膚與局部血液循環，並提供如廁或飲水需求。這不僅是臨床指引，也是法律對於病人人權的保護。關於選項 C，約束醫囑通常需要醫師在 1 小時內親自評估，且必須在 24 小時內補簽名（而非 48 小時）。選項 D 是嚴重錯誤，約束帶絕不能繫在床欄，因為床欄移動時會拉扯病人肢體導致受傷，必須繫在床架（Bed frame）上。整體而言，護理師必須在「保護病人不自傷」與「預防約束造成的生理損傷」之間取得平衡，並詳實記錄評估結果。
For a restrained client, meeting physiologic needs and preventing complications are central nursing priorities. Although monitoring circulation (A) is important, the NCLEX-standard intervention is to release the restraint every 2 hours to perform full range-of-motion exercises, assess skin and local circulation, and address toileting or fluid needs. This is both a clinical guideline and a legal safeguard for the client's rights. Regarding option C, restraint orders typically require the physician to perform an in-person assessment within 1 hour and to sign the order within 24 hours (not 48). Option D is a serious error: restraints must never be tied to the side rails, because movement of the rails will pull on the client's limbs and cause injury; restraints must be secured to the bed frame. Overall, the nurse must balance protecting the client from self-harm with preventing physical injury from the restraint itself, and must thoroughly document all assessments.
美國對約束（Restraint）的管理極其嚴格，視其為侵犯人權的最後手段，醫囑時效（成人 4 小時、青少年 2 小時）與醫師親自評估的要求非常明確。台灣雖然也有規範，但在實際執行中，醫師補開醫囑的時間往往較具彈性，且對「床欄是否算約束」的認知與美國 NCLEX 標準有落差。