— 心理社會完整性 · MEDIUM · MCQ —
護理師觀察到一位處於躁期（Mania）的雙極性疾患病人侵犯他人個人空間。哪項措施最合適？
A nurse observes a client with bipolar disorder, mania phase, intruding on other clients' personal space. Which action is the most appropriate?
- ADiscuss the behavior in the next group meeting在下次團體會議中討論該行為
- BIgnore the behavior to avoid conflict忽略該行為以避免衝突
- CAsk the other clients to leave the room要求其他病患離開房間
- DFirmly and calmly set limits on the behavior✓ 正解堅定且平靜地對該行為設定界限
— Explanation · 中文詳解 —
躁期病人常見特徵為界線模糊，護理師應採取「堅定且冷靜」的態度設立界限（Limit setting），這能提供病人安全感並保護環境秩序。B 選項會讓病人失去行為準則；A 選項不即時，病人無法修正；C 選項過度遷就躁動行為，未解決根本問題。
Severe burns cause significant fluid shifts into interstitial spaces, leading to hypovolemia and decreased renal perfusion indicated by low urine output. The priority nursing intervention is to increase the intravenous fluid infusion rate to restore circulating volume and prevent acute kidney injury.
✦ 台美臨床差異
美國護理師對 Limit setting 的技巧受過嚴格訓練，台灣護理師執行時常需配合保護隔離措施以維護病人安全。