一位 28 歲患有廣泛性焦慮症的個案至診所,主訴心悸、盜汗及瀕死感。護理師應優先採取的介入措施為何?
A 28-year-old client with generalized anxiety disorder presents to the clinic reporting palpitations, diaphoresis, and a feeling of impending doom. Which intervention is the highest priority for the nurse?
- AStay with the client and provide a calm environment✓ 正解留在病人身邊並提供安靜的環境
- BAdminister the prescribed PRN anxiolytic medication給予處方備用的抗焦慮藥物
- CTeach the client deep breathing exercises教導病人深呼吸運動
- DExplore the triggers of the current anxiety attack探討目前焦慮發作的誘發因素
面對焦慮發作(特別是恐慌樣症狀),護理的首要任務是確保個案的安全感與降低過度刺激。陪伴個案不僅能提供情緒支持,也能協助護理師觀察生理變化。在急性期,個案難以學習新技巧或進行深入的心理探索,應先穩定環境再考慮藥物或衛教。
When dealing with an anxiety attack (especially with panic-like symptoms), the nursing priority is to ensure the patient's sense of safety and to reduce excessive stimulation. Staying with the patient not only provides emotional support but also enables the nurse to observe physiological changes. In the acute phase, the patient finds it difficult to learn new techniques or engage in deep psychological exploration, so the environment should be stabilized first before considering medication or patient education.
美護理師較強調治療性護理關係的使用;台灣臨床多依醫囑給予抗焦慮藥物,護理師陪伴的重要性常被護理行政事務稀釋。