— 照護管理 · MEDIUM · SATA —
護理師為需約束的病人規劃護理，必須執行哪些行動？（選所有適合的）
A nurse is planning care for a client who has a prescription for a restraint. Which actions must the nurse perform? (Select all that apply.)
- AObtain a new physician prescription every 24 hours✓ 正解每 24 小時取得新的醫師處方
- BCheck neurovascular status every 2 hours每 2 小時檢查神經血管狀態
- CEnsure two fingers can fit between the restraint and the client's skin✓ 正解確保約束帶與個案皮膚之間能容納兩根手指的空間
- DDocument the client's behavior and reason for the restraint✓ 正解記錄個案的行為及實施約束的原因
- EProvide ROM exercises during regular checks✓ 正解在定期檢查期間提供關節活動度（ROM）運動
— Explanation · 中文詳解 —
約束規範要求：醫師醫囑必須每日更新（法規要求）；約束帶必須保持寬鬆度（兩指間隙以防壓瘡或神經損傷）；必須詳細記錄執行原因與病人行為反應；定期檢查時需提供關節活動（ROM）以促進循環與防止攣縮。B 錯誤：神經血管評估應至少每 1-2 小時進行，但在臨床實務中，對於高風險病人通常為 1 小時，兩小時過長。
Restraint protocols require daily physician renewal, proper fitting to prevent injury, and detailed documentation of behavior and necessity. Nurses must also provide range-of-motion exercises during checks to promote circulation and prevent contractures, while performing neurovascular assessments at least hourly.
✦ 台美臨床差異
美國法規對約束記錄極其嚴格，常需針對約束進行多領域團隊評估；台灣亦有相關健保規範，但執行面側重於家屬同意書簽署。