— 照護管理 · MEDIUM · MCQ —
病人表現焦躁並試圖拔除靜脈導管（IV）。護理師應優先嘗試哪項介入措施？
A nurse is caring for a client who is agitated and attempting to pull out their IV line. Which intervention should the nurse attempt first?
- ACall security to sit with the client呼叫保全與病人坐在一起
- BApply bilateral wrist restraints應用雙側手腕約束帶
- CRequest a prescription for a sedative medication請求鎮靜劑處方
- DOrient the client and use distraction techniques✓ 正解引導病人定向並使用分散注意力的技巧
— Explanation · 中文詳解 —
根據「最少限制原則（Least restrictive environment）」，在考慮使用約束（Restraints）或藥物前，護理師應先嘗試非侵入性的方法，如重新定向（Orientation）、陪伴或轉移注意力（Distraction）。約束被視為最後手段，且需要定期評估與更新醫囑。優先採取非藥物、非物理性的介入是護理標準。
Interventions should follow the least restrictive principle, prioritizing non-invasive strategies before considering restraints. The nurse should first attempt to orient the client and use distraction techniques to address agitation safely. Physical or chemical restraints are reserved for situations where these measures fail and there is an imminent risk of harm.
✦ 台美臨床差異
美國法律對约束（Restraint）有極嚴格的時限與紀錄要求；台灣臨床上约束使用較普遍，但目前也正推廣「零約束」觀念。