一位 25 歲患有廣泛性焦慮症的病患來到診所，出現心悸與顫抖，護理師觀察到病患正在過度換氣。護理師最優先的介入措施為何？
A 25-year-old client with a history of generalized anxiety disorder presents to the clinic with palpitations and trembling. The nurse observes the client hyperventilating. What is the most appropriate initial nursing intervention?
- AEncourage the client to discuss the source of anxiety鼓勵病人討論焦慮的來源
- BInstruct the client to breathe into a paper bag指示病人對著紙袋呼吸
- CAdminister an as-needed benzodiazepine給予按需使用的苯二氮平類藥物
- DSpeak in a calm, firm, and concise manner✓ 正解以冷靜、堅定且簡潔的方式說話
面對焦慮發作的病患，護理師應先建立安全感並降低其感知到的威脅。冷靜、清晰且簡短的溝通能幫助病患減輕當下的恐懼，防止焦慮惡化。紙袋呼吸法目前已不建議使用，因為這可能引發缺氧。藥物雖可使用但非首選，而探索焦慮源應在病患情緒穩定後進行。
When caring for a client during an anxiety attack, the nurse should first establish a sense of safety and reduce the perceived threat. Calm, clear, and concise communication helps relieve immediate fear and prevents the anxiety from worsening. Paper bag rebreathing is no longer recommended, as it can produce hypoxia. Medication may be used but is not the first-line choice, and exploration of the source of anxiety should occur only after the client's emotional state has stabilized.
美方護理師在心理衛生方面有更多協調權；台灣臨床多由精神科醫師主導藥物決策，護理師偏向環境控制與情緒支持。