一位車禍後的成人病人被送至急診，情緒躁動並拒絕治療。護理師優先行動為何？
An adult client is brought to the ED after a motor vehicle accident. The client is combative and refuses care. What is the nurse's priority action?
- AAssess for potential head injury or hypoxia✓ 正解評估是否有潛在的頭部外傷或缺氧
- BAdminister a sedative to calm the client給予鎮靜劑以使個案安靜
- CHave the client sign an Against Medical Advice (AMA) form請個案簽署反對醫療建議（AMA）表格
- DNotify the security team to restrain the client通知保全團隊對個案進行約束
急診護理中，躁動病人常伴隨潛在的生理危機，如創傷性腦損傷（TBI）、缺氧、低血糖或休克。在評估病人是否有能力拒絕治療（Capacity）之前，護理師必須先排除這些會導致意識混亂的生理病理原因。採取ABC（Airway, Breathing, Circulation）原則評估生理狀況，是保障病人安全與法律權益的首要任務。
Combative behavior in a trauma patient may indicate underlying physiological crises such as traumatic brain injury, hypoxia, or shock, which must be ruled out before assessing decision-making capacity. Administering sedatives or restraining the client without assessment could mask critical symptoms or delay life-saving interventions. The nurse's priority is to perform a rapid physical assessment using ABCs to identify and treat any reversible causes of the altered mental status.
在美國，病人若有意識改變（Altered mental status），即便他想簽 AMA，護理師與醫師也必須以「Involuntary hold」方式先留置病人進行穩定與檢查。