一位病人因攻擊行為被施以機械性約束。為確保安全，護理師應優先執行哪些措施？（選所有適合的）
A client is placed on mechanical restraints due to aggressive behavior. Which nursing intervention is a priority to ensure safety? (Select all that apply.)
- AAssess neurovascular status of the restrained limbs every 15 minutes✓ 正解每15分鐘評估約束肢體的神經血管狀況。
- BOffer fluids and toileting every 2 hours✓ 正解每2小時提供水分並協助如廁。
- CTie the restraint straps to the side rails of the bed將約束帶綁在床欄上。
- DDocument the behavior that necessitated the restraints✓ 正解記錄需要使用約束的行為。
- ERenew the restraint order every 24 hours for an adult client每24小時重新開立成人病人的約束醫囑。
約束病人需極高安全監測：每 15 分鐘觀察神經血管狀態（A）以防組織壞死，每 2 小時提供基本需求（B）。必須詳實記錄約束原因（D）。C 錯誤：約束帶應繫於床架而非床欄，以免移動床欄時拉傷病人。E 錯誤：針對行為問題的約束，成人醫囑通常需每 4 小時重新評估續開，而非 24 小時。
Frequent neurovascular assessments every 15 minutes are essential to prevent circulatory impairment and nerve damage. Basic needs, including hydration and toileting, must be addressed every 2 hours to maintain patient comfort and hygiene. Documentation of the specific behavior necessitating restraints is required for legal justification. Restraints should never be tied to side rails, and adult orders for violent behavior require renewal every 4 hours, not 24.
美國法規（Joint Commission）對約束時限與醫囑更新極為嚴格；台灣臨床實務中，非精神科病房的約束醫囑更新頻率通常較為寬鬆。