病人躁動並試圖拔除靜脈導管。在替代方案無效後，醫師開立了手腕約束醫囑。哪項護理行為是必要的？

當病人需要使用身體約束（physical restraints）時，護理師的首要考量是病人的安全與福祉。約束雖然是為了保護病人免於傷害，但其本身也可能造成潛在的危險，例如循環受損、皮膚破損、神經損傷，甚至心理創傷。因此，在執行醫囑時，護理師必須嚴格遵守相關規範，確保約束的正確應用與頻繁監測。這不僅是為了符合醫療法規，更是為了提供以病人為中心的照護，盡可能減少約束帶來的負面影響。 正確的護理行為應側重於持續評估約束部位的完整性與功能，以預防任何併發症的發生。這包括監測肢體的血液循環、感覺功能、運動功能及皮膚狀況，並在需要時進行鬆綁活動，確保病人的基本需求得到滿足。約束僅在所有替代方案都失敗後才被考慮，且必須有明確的醫囑支持，並定期評估其持續的必要性。

When a patient requires physical restraints, the nurse's foremost consideration is the patient's safety and well-being. Although restraints are intended to protect patients from harm, they themselves may produce potential dangers, such as impaired circulation, skin breakdown, nerve injury, and even psychological trauma. Therefore, when carrying out the medical order, the nurse must strictly adhere to the relevant standards, ensuring correct application and frequent monitoring. This is not only to comply with regulatory requirements but also to provide patient-centered care that minimizes the negative effects of restraints. The correct nursing actions should focus on continuous assessment of the integrity and function of the restrained area to prevent any complication. This includes monitoring circulation, sensation, motor function, and skin condition of the involved extremity, and performing release with active or passive range-of-motion exercises as needed to meet the patient's basic needs. Restraints should be considered only after all alternative measures have failed, must be supported by a clear medical order, and require regular re-evaluation of the continued need.

在美國，關於身體約束（physical restraints）的規範非常嚴格，尤其強調替代方案的嘗試、醫囑的頻繁更新（例如，針對暴力行為的約束，成人醫囑可能每4小時需更新一次；非暴力約束則可能每24小時更新），以及嚴密的監測頻率。台灣的約束規範也強調醫囑、替代方案與監測，但醫囑更新頻率和監測的具體時間點可能與美國有所不同，例如台灣常見長期約束醫囑可能較長效，但臨床上仍會要求頻繁評估。NCLEX 考試會依循美國的標準，強調更頻繁的醫囑更新與監測，以最大程度保障病人權益與安全。