一位 28 歲患有廣泛性焦慮症的個案來到診所，主訴心悸與顫抖等身體症狀。護理師的優先護理行動為何？
A 28-year-old client with a history of generalized anxiety disorder presents to the clinic reporting physical symptoms such as palpitations and tremors. What is the nurse's priority action?
- APerform a physical assessment to rule out organic causes✓ 正解進行身體評估以排除器質性病因
- BInstruct the client on deep breathing techniques指導個案深呼吸技巧
- CExplore the underlying causes of the client's stress探討個案壓力的根本原因
- DAdminister an as-needed benzodiazepine給予處方備用苯二氮平類藥物
面對呈現身體焦慮症狀的個案，護理專業的首要任務是確保安全與排除潛在的器質性疾病，如甲狀腺功能亢進或心律不整。在排除生理問題前，不應直接歸因於心理焦慮，以免延誤治療。評估是護理程序的第一步，確保診斷準確後再進行心理介入。
When dealing with a client presenting somatic anxiety symptoms, the nursing priority is to ensure safety and rule out potential organic diseases such as hyperthyroidism or arrhythmia. Before excluding physiological causes, symptoms should not be directly attributed to psychological anxiety, in order to avoid delayed treatment. Assessment is the first step of the nursing process; psychological intervention should be implemented only after ensuring diagnostic accuracy.
美國護理師常執行完整身體評估；台灣護理師在門診常輔助醫師進行身體評估，但診斷權責多在醫師。