護理師照顧一位情緒暴躁的病人。哪項措施是安全優先考量？
A nurse is caring for a client who is experiencing a violent outburst. Which is the safest priority action?
- AMaintain a safe distance and call for assistance✓ 正解保持安全距離並尋求協助
- BAttempt to physically restrain the patient alone嘗試單獨對病人進行身體約束
- CReason with the patient to calm them down immediately與病人講道理以使其立即冷靜
- DAdminister an oral sedative without an order未經醫囑給予口服鎮靜劑
面對暴力行為，護理師的首要原則永遠是「自身安全（Safety First）」。當病人出現暴力傾向時，護理師應評估環境，確保有退路，並立即尋求協助。單獨對抗暴怒病人極易導致護理師受傷，且可能激化病人的攻擊行為。臨床上，應遵循機構的暴力應變程序（Code Grey/White），等待足夠人力支援再採取進一步行動，切勿嘗試單槍匹馬控制病人。
When facing violent behavior, the nurse's first principle is always 'safety first.' If a client exhibits violent tendencies, the nurse should assess the environment, ensure an escape route, and immediately seek assistance. Attempting to confront an agitated client alone often results in nurse injury and may escalate the client's aggression. Clinically, the institution's violence response protocol (e.g., Code Grey/White) should be followed, with sufficient staffing in place before any further action is taken; the nurse should never try to control the client single-handedly.
美國醫院對暴力行為有極嚴格的Code系統（如Code Grey），護理師受過專業暴力防範訓練（如CPI），強調團隊合作與非侵入性介入，台美在安全優先的原則上一致。