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心理社會完整性 · MEDIUM · SATA

一位恐慌發作的個案,護理師應採取哪些介入措施?(選所有適合的)

A nurse is caring for a client experiencing a panic attack. Which interventions are appropriate? (Select all that apply.)

  • AUse short, simple sentences✓ 正解
    使用簡短、簡單的句子
  • BLeave the client alone to reduce stimulation
    讓病人獨處以減少刺激
  • CMaintain a calm, authoritative manner✓ 正解
    保持冷靜、權威的態度
  • DPlace the client in a quiet, low-stimulation environment✓ 正解
    將病人安置在安靜、低刺激的環境中
  • EInstruct the client to breathe into a paper bag
    指示病人用紙袋呼吸
Explanation · 中文詳解

恐慌發作時個案認知能力下降,溝通應簡潔明確。環境應保持安靜以減少感官刺激,護理師應展現專業與冷靜以提供安全感。不應讓個案獨處(有自傷或失控風險)。過度換氣時不再鼓勵用紙袋呼吸,因可能引發缺氧,目前傾向指導腹式呼吸。

During a panic attack, the client's cognitive ability is reduced, so communication should be concise and clear. The environment should be kept quiet to reduce sensory stimulation, and the nurse should display a professional, calm demeanor to provide a sense of safety. The client should not be left alone (risk of self-harm or loss of control). Paper-bag rebreathing is no longer encouraged during hyperventilation, as it can induce hypoxia; current practice favors guiding the client through diaphragmatic breathing.

✦ 台美臨床差異

美國護理教育強調禁止獨處,台灣實務上也相同,但在資源不足時可能需要家屬協助陪伴。

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