— 照護管理 · MEDIUM · MCQ —
護理師照顧一位混亂且躁動的病人，最合適的初步護理措施為何？
A nurse is managing a client who is confused and agitated. What is the most appropriate initial nursing intervention?
- APlace the client in a private room and lock the door將個案安置於私人病房並鎖上房門
- BUse verbal de-escalation techniques to calm the client✓ 正解使用口語去激化技巧安撫個案
- CApply physical restraints immediately立即實施身體約束
- DAdminister an antipsychotic medication給予抗精神病藥物
— Explanation · 中文詳解 —
處理躁動病人時，應遵守「最少限制原則（Least restrictive alternative）」。初步應使用口頭安撫與去升級技巧（Verbal de-escalation），嘗試釐清躁動原因（如尿急、缺氧、疼痛）。約束與藥物屬於後續手段，若直接執行且未嘗試溝通，違反倫理與醫療常規。
The least restrictive alternative principle dictates that verbal de-escalation techniques should be the first intervention for an agitated client. These methods are ethical and effective for calming the client and identifying underlying causes before considering more restrictive measures like restraints or medications.
✦ 台美臨床差異
美國非常重視去升級（De-escalation）技巧；台灣臨床受限於環境，有時會傾向較早採用保護性約束。