護理師照護一位使用身體約束的病人，下列哪些是護理師的職責？（選所有適合的）
A nurse is caring for a client who is being physically restrained. What are the nurse's responsibilities? (Select all that apply.)
- ACheck the restraint straps every 2 hours每兩小時檢查約束帶
- BDocument the type of restraint and reason for use✓ 正解記錄約束類型及使用原因
- CObtain a physician's order for the restraint within 1 hour在一小時內取得醫師對約束的醫囑
- DPerform neurovascular checks on the restrained limb✓ 正解對受約束的肢體進行神經血管檢查
- EEnsure the restraint is tied to the bed rail for safety確保約束帶綁在床欄上以確保安全
約束病人必須符合法律規範。醫囑需每 24 小時更新，且需持續監測神經血管狀態（末梢循環）。約束必須綁在床架（非床欄）以防升降床時造成傷害。選項 A 檢查頻率通常較 2 小時頻繁（如 1 小時），選項 C 需有醫囑但非一定一小時內補開，視機構政策而定。
Nurses must document the type of restraint used and the clinical justification for its application to ensure legal and clinical accountability. Additionally, frequent neurovascular assessments of the restrained extremity are critical to detect early signs of compromised circulation or nerve damage. Restraints should be secured to the bed frame rather than side rails to prevent injury during bed adjustment, and they require more frequent monitoring than every two hours per standard protocols.
美國對約束（Restraint）規範嚴格，包含時效性和行為約束（Behavioral）與醫學約束（Medical）的差別；台灣法規較寬鬆，但近年也趨向以更低限制的約束為主。