一位病人安排了選擇性手術，外表明顯顫抖並表示：「我緊張到根本記不得外科醫師跟我說過的手術風險。」護理師應如何歸類該病人的焦慮程度？
A client is scheduled for an elective surgery and is visibly trembling. The client states, 'I'm so nervous that I can't even remember what the surgeon told me about the risks.' How should the nurse categorize the client's level of anxiety?
- AMild anxiety輕度焦慮
- BModerate anxiety中度焦慮
- CPanic level anxiety恐慌級焦慮
- DSevere anxiety✓ 正解重度焦慮
焦慮程度分為四級。重度焦慮（Severe Anxiety）的特徵是知覺場域顯著縮小，病人專注於單一細節，無法學習或處理資訊（如記不得風險說明），且伴隨明顯生理症狀（如顫抖）。輕度焦慮能增加警覺性；中度焦慮知覺場域縮小但仍可學習；恐慌級焦慮則會出現人格解離或極度失控。此案例符合重度指標。
Anxiety is classified into four levels. Severe anxiety is characterized by a markedly narrowed perceptual field, with the client focused on a single detail and unable to learn or process information (such as being unable to recall the explanation of risks), accompanied by prominent physiological symptoms (such as trembling). Mild anxiety enhances alertness; moderate anxiety narrows the perceptual field but still allows learning; and panic-level anxiety results in depersonalization or extreme loss of control. This case fits the severe-anxiety profile.
全美護理教育統一使用 Peplau 的焦慮分級；台灣護理教科書亦採用此標準，臨床評估一致性高。