一位 35 歲患有廣泛性焦慮症的個案，出現呼吸急促、心跳過速以及強烈的瀕死感。護理師應採取的最優先行動為何？
A 35-year-old client with a history of generalized anxiety disorder presents with rapid breathing, tachycardia, and a feeling of impending doom. Which action is the priority for the nurse?
- ARemain with the client and maintain a calm, quiet environment✓ 正解陪伴個案並維持安靜平和的環境
- BAdminister the PRN lorazepam immediately立即給予備用劑量的勞拉西泮
- CEncourage the client to discuss the source of their anxiety鼓勵個案討論焦慮的來源
- DInstruct the client to breathe slowly into a paper bag指示個案用紙袋緩慢呼吸
急性焦慮發作時，首要任務是確保個案安全並降低刺激，防止症狀惡化。護理師陪伴能提供支持感，安靜環境可減少感官過度刺激。D 選項現已不建議使用紙袋，因為會造成二氧化碳滯留；C 需經醫囑且非首要；D 在個案焦慮高峰期無法有效溝通，應待情緒平復後再進行。
During an acute anxiety attack, the first priority is to ensure client safety and reduce stimulation to prevent symptoms from worsening. The nurse's presence provides a sense of support, and a quiet environment reduces sensory overstimulation. Option D: paper bag breathing is no longer recommended because it causes carbon dioxide retention. C requires a physician order and is not the first action; C is ineffective during the peak of anxiety, as communication should wait until emotional calm is restored.
台灣病房常因人力限制難以持續陪伴，多傾向給藥控制，美國護理師則更強調環境調整與心理陪伴。