一位 45 歲患有廣泛性焦慮症的個案，主訴心悸、顫抖及強烈的瀕死感。護理師首要的介入措施為何？
A 45-year-old client with a history of generalized anxiety disorder presents with reports of palpitations, tremors, and a sense of impending doom. Which intervention is the nurse's initial priority?
- AAdminister an ordered PRN benzodiazepine給予處方上的備用苯二氮平類藥物
- BEncourage the client to discuss the source of their anxiety鼓勵個案討論其焦慮的來源
- CTeach the client deep breathing exercises教導個案深呼吸練習
- DProvide a calm, quiet environment and remain with the client✓ 正解提供安靜平和的環境並陪伴個案
急性焦慮發作時，個案常失去安全感與控制感。護理師應先提供物理上的安全感，透過「陪伴」降低焦慮強度。Benzodiazepine 雖有效，但通常在非藥物治療無效或焦慮過度嚴重時才會作為第一選擇。討論壓力源應在焦慮緩解後進行，呼吸練習則需個案具備一定專注力才有效。
During an acute anxiety episode, clients often lose their sense of safety and control. The nurse should first provide physical safety by 'being present' to reduce the intensity of anxiety. Although benzodiazepines are effective, they are usually used only when non-pharmacologic interventions fail or when anxiety is severe. Exploring the source of stress should occur after the acute anxiety has eased, and breathing exercises are effective only when the client has enough focus to follow instructions.
美國護理師在急性焦慮時有更多自主權採取非藥物處置；台灣臨床常受限於人力，較依賴藥物控制。