一位腫瘤診所護理師正運用護理過程管理一位 35 歲、新確診早期乳癌的病患。這位病患安靜坐著，緊抓她的皮包，盯著牆壁。根據護理過程，護理師第一件該做的事為何？
An oncology clinic nurse is utilizing the nursing process to manage a 35-year-old female client newly diagnosed with early-stage breast cancer. The client sits quietly, gripping her purse tightly, and stares blankly at the wall. According to the nursing process, what should the nurse do first?
- AReassure the client cheerfully that early-stage breast cancer has incredibly high survival rates.愉快地向病人保證早期乳癌的存活率極高。
- BAsk an open-ended question to assess the client's current emotional state and understanding.✓ 正解提出開放式問題以評估病人目前的情緒狀態和理解程度。
- CRefer the client immediately to an external psychosocial support group.立即將病人轉介至外部心理社會支持團體。
- DInitiate educational teaching regarding cosmetic options for breast reconstruction surgery.開始進行有關乳房重建手術美容選擇的教育衛教。
本題測驗護理過程 (Nursing process: Assessment) 與治療性溝通。護理過程永遠的第一步驟是『評估 (Assess/ADPIE)』。病患剛收到癌症宣判且表現出呆滯、緊抓物品（休克的肢體語言）。直接轉介團體 (C) 或開始衛教 (D) 都屬於「介入」。如果在病患恐慌發作時塞衛教資訊，病患無法吸收。第一步是利用開放式溝通技巧「評估」情緒。選項 A 給予虛假保證 (False reassurance) 會阻斷溝通，是禁忌。
The nursing process always begins with ASSESSMENT (ADPIE). A newly diagnosed client showing shock/distress signals (quiet, gripping purse, blank stare) needs the nurse to assess current emotional state and understanding via open-ended questioning before launching educational content (D), referring out (C), or offering false reassurance (A). False reassurance specifically invalidates distress and blocks communication.
治療性溝通第一步永遠選「評估(Assess)」或「問開放式問題(Open-ended question)」。