一位 45 歲患有廣泛性焦慮症的個案，主訴心悸、出汗、胸悶，護理師觀察到個案正在過度換氣。下列哪項護理措施最為優先？
A 45-year-old client with a history of generalized anxiety disorder presents with reports of palpitations, sweating, and chest tightness. The nurse observes the client is hyperventilating. Which initial intervention is most appropriate?
- AInstruct the client to breathe into a paper bag指示個案使用紙袋呼吸
- BSpeak in a calm, clear, and low-pitched voice✓ 正解以平靜、清晰且低沉的語調說話
- CLeave the client alone to reduce environmental stimuli讓個案獨處以減少環境刺激
- DAdminister an as-needed benzodiazepine immediately立即給予按需處方的苯二氮平類藥物
面對過度換氣的焦慮個案，護理師應先建立安全感。冷靜且低沈的語調有助於穩定情緒，引導其調節呼吸頻率。使用紙袋呼吸已非現代標準護理指引，因為這可能導致二氧化碳過高。給藥需醫囑且非首選，離開病人則可能加劇恐慌感。
When dealing with a hyperventilating, anxious client, the nurse should first establish a sense of safety. A calm, low tone of voice helps stabilize emotions and guide the patient in regulating respiratory rate. Paper-bag breathing is no longer part of modern standard nursing guidelines because it can lead to excessive carbon dioxide levels. Medication requires a physician's order and is not the first choice, and leaving the patient can intensify the sense of panic.
美國護理師常依據病房 protocol 進行溝通引導；台灣護理師執行此類措施時亦強調護病溝通與安撫。