一位 45 歲患有廣泛性焦慮症的個案，出現心悸、冒汗及瀕死感。護理師應優先採取何種措施？
A 45-year-old client with a history of generalized anxiety disorder presents with reports of palpitations, sweating, and feelings of impending doom. Which intervention is the priority for the nurse to implement?
- AMaintain a calm, quiet, and safe environment✓ 正解維持安靜、平和且安全的环境
- BTeach the client deep breathing exercises教導個案深呼吸練習
- CAdminister PRN medication for anxiety給予處方備用抗焦慮藥物
- DIdentify the precipitating stressor識別誘發因素
面對急性焦慮發作的個案，環境調控是首要目標。減少外在感官刺激能協助降低個案的警覺狀態，並預防焦慮進一步升級為驚恐發作。深呼吸練習雖有效，但需在個案情緒稍微穩定後才能進行；藥物干預為輔助；找出壓力源則屬於後續評估範疇。
In acute anxiety, environmental control is the priority. Reducing external sensory stimulation helps lower the client's arousal level and prevents anxiety from escalating into a panic attack. Deep breathing exercises are useful but require the client to be sufficiently calm to follow instructions; medication is adjunctive; identifying the precipitating stressor is a later assessment step.
美台護理對焦慮症急性發作均採取「環境減敏」原則，台灣臨床多強調醫囑給藥，美國則更強調護理師主導的非藥物環境干預。