— 安全與感染控制 · MEDIUM · MCQ —
對於一名使用手腕約束帶的病人，哪項評估結果應優先通報？
Which assessment finding is a priority to report for a client who is in wrist restraints?
- AThe client's hand is cool to the touch and pale.✓ 正解病人手部觸摸冰冷且蒼白
- BThe client is yelling at the staff members.病人對工作人員大聲叫囂
- CThe restraint ties are secured with a quick-release knot.約束帶綁帶使用快速解開結固定
- DThe client has not voided for 4 hours.病人已 4 小時未排尿
— Explanation · 中文詳解 —
約束最嚴重的併發症是血循受阻導致神經血管損傷。手部冰冷且蒼白顯示末梢灌流不足，必須立即鬆開約束並通報處理，否則可能導致組織壞死。A 是行為表現需監測但非緊急醫療危險；C 排尿問題需關注但非約束直接導致的急性損傷；D 使用快拆結（Quick-release knot）是正確的標準做法，不需通報。
Coolness and pallor in the restrained hand indicate compromised circulation and potential neurovascular injury, which is a priority emergency requiring immediate release of the restraint and notification of the provider. While agitation, proper knot usage, and urine output are relevant assessments, they do not pose the same immediate threat of tissue necrosis as ischemia.
✦ 台美臨床差異
美國 NCLEX 非常強調神經血管評估（Neurovascular check）；台灣醫院臨床指引亦要求每兩小時評估一次並記錄。