一位 45 歲患有廣泛性焦慮症的個案出現心悸、震顫及強烈的瀕死感。護理師應優先採取什麼措施？
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 priority?
- APerform a comprehensive physical assessment進行全面的身體評估
- BAdminister PRN anxiolytic medication給予 PRN 抗焦慮藥物
- CAsk the client to list all current stressors請個案列出所有目前的壓力源
- DInstruct the client to breathe slowly and deeply✓ 正解指示個案緩慢且深長地呼吸
面對急性焦慮發作，優先採取非藥物介入以穩定生理反應。腹式呼吸能啟動副交感神經，幫助個案控制換氣過度並降低心跳速度，恢復平靜。給藥需醫囑且為次要選擇，詢問壓力源會增加認知負荷，全面身體評估則應在個案情緒穩定後進行。
When confronted with an acute anxiety attack, nonpharmacologic interventions are used first to stabilize the physiologic response. Diaphragmatic breathing activates the parasympathetic nervous system, helping the client control hyperventilation, decrease the heart rate, and regain calm. Medication administration requires an order and is a secondary option, asking about stressors increases cognitive load, and a comprehensive physical assessment should be performed only after the client's emotions have stabilized.
台美均將呼吸練習視為焦慮的第一線護理介入，無明顯差異。