一位 45 歲患有廣泛性焦慮症的個案，出現心跳加速、顫抖及瀕死感。護理師首要介入措施為何？
A 45-year-old client with a history of generalized anxiety disorder presents with a rapid heart rate, tremors, and a sense of impending doom. Which intervention is the highest priority for the nurse?
- AMaintain a calm and safe environment維持安靜且安全的環境
- BAdminister an as-needed dose of benzodiazepine給予處方備用的苯二氮平類藥物劑量
- CInstruct the client to use deep breathing exercises指導個案使用深呼吸練習
- DAssess the client for recent medication changes✓ 正解評估個案近期的用藥變化
面對 45 歲焦慮病人主訴「心搏加速、顫抖、瀕死感」，依 NCLEX 安全優先原則，必須先排除生理急症（特別是 MI、甲狀腺風暴、藥物副作用、戒斷症狀）。D. 評估近期用藥變化是合理的優先評估，可釐清是否為藥物相關（β2 致效劑、SSRI 副作用或 BZD 戒斷）。其他選項：C 深呼吸雖有效但應在排除生理因素後使用；B 給藥前需先評估病因；C 安靜環境為支持性處置。
For a 45-year-old anxious patient reporting rapid heartbeat, tremor, and a sense of impending doom, the NCLEX safety-first principle requires first ruling out physiologic emergencies (especially MI, thyroid storm, medication side effects, and withdrawal). Option D — assessing recent medication changes — is a reasonable initial priority, as it helps clarify whether the cause is drug-related (β2 agonists, SSRI side effects, or benzodiazepine withdrawal). For the other options: A — deep breathing is helpful but should be used after physiologic causes are excluded; B — medications should not be given before the cause is assessed; C — a quiet environment is a supportive measure.
美國護理師常依據病房 protocol 進行環境調整；台灣醫療環境較吵雜，護理師需花更多心力建立專屬的談話空間。