— 安全與感染控制 · HARD · MCQ —
一位高齡病人意識混亂，試圖爬下床。護理師的第一個行動應為何？
An elderly client is confused and attempting to climb out of bed. What should be the nurse's first action?
- AAssess the reason for the client's behavior✓ 正解評估病人行為的原因
- BCall the physician for an order for restraints通知醫師開立約束医嘱
- CApply physical restraints實施物理約束
- DAdminister a PRN sedative給予處方標示PRN的鎮靜劑
— Explanation · 中文詳解 —
護理決策的黃金準則之一是「最少約束原則（Least Restrictive Environment）」。當病人出現混亂行為時，必須首先評估其潛在的生理或心理需求，例如尿急、疼痛、低血糖、缺氧或藥物副作用。直接約束或給藥可能掩蓋病人的真實病情，且具有法律與倫理風險。只有在評估後確定無其他方法且病人有立即危險時，才考慮採取約束措施。
The nurse must first assess the underlying cause of the client's confusion and agitation, such as pain, hypoxia, or urinary retention, to provide individualized care. Interventions like restraints or sedatives should be avoided initially as they are restrictive and may mask the true medical issue.