— 照護管理 · MEDIUM · MCQ —
一位護理師照顧一位表現出攻擊行為並在走廊踱步的病人。護理師應先採取哪項措施？
A nurse is caring for a client who is demonstrating aggressive behavior and pacing in the hallway. Which action should the nurse take first?
- ASpeak to the client in a calm, low voice以平靜、低沉的聲音與病人交談
- BRemove other clients from the area✓ 正解將其他病人帶離該區域
- CAdminister an PRN sedative給予處方之 PRN 鎮靜劑
- DCall for security personnel to restrain the client呼叫保全人員對病人實施約束
— Explanation · 中文詳解 —
面對具攻擊性行為的病人，優先考慮的是其他人員與病人的安全。將其他無關人員移出該區域（Clear the area）是優先的保護行動，能防止潛在的衝突升級並保護無辜者。過早使用束縛或藥物涉及倫理與法律考量，而冷靜溝通則為後續步驟。
The nurse's first priority when encountering aggressive behavior is to ensure the safety of all individuals in the environment. Removing other clients from the area prevents potential harm and reduces stimuli that could escalate the situation. De-escalation techniques, medication, or restraints are subsequent steps that should only be considered after the immediate environment is secured.
✦ 台美臨床差異
美國醫院有嚴格的行為安全政策與團隊響應（Code Gray）；台灣則較依賴護理人員與警衛協調，且對約束使用法規更趨嚴格。