一位 25 歲患有廣泛性焦慮症的病患至門診，主訴心悸、顫抖及瀕死感。護理師觀察到病人在候診區來回踱步。哪項措施為最高優先級？
A 25-year-old client with a history of generalized anxiety disorder presents to the clinic with reports of tachycardia, tremors, and a sense of impending doom. The nurse observes the client pacing in the waiting room. Which intervention is the highest priority?
- AReview the client's medication compliance history檢視個案的用藥順從史
- BAdminister the prescribed PRN anxiolytic medication給予處方劑量的 PRN 抗焦慮藥物
- CMaintain a calm environment and stay with the client✓ 正解維持安靜的環境並陪伴個案
- DInstruct the client to practice deep breathing techniques指導個案練習深呼吸技巧
面對急性焦慮發作的病人，首要之務是提供安全且穩定的環境，護理師保持陪伴能降低病人的無助感。焦慮急性期時，病人的認知功能受損，複雜指導（如呼吸技巧）效果有限。藥物給予雖有效，但護理師的人際陪伴與環境調整應優先進行，以利建立治療性關係。
When facing a client with an acute anxiety attack, the first priority is to provide a safe and stable environment; the nurse's presence helps reduce the client's sense of helplessness. During acute anxiety, the client's cognitive functioning is impaired, and complex instructions (such as breathing techniques) have limited effect. While medications are effective, the nurse's interpersonal presence and environmental adjustments should come first in order to establish a therapeutic relationship.
美國護理師常執行去 escalate 技巧；台灣臨床多由醫師評估，護理師則多負責觀察與依醫囑給藥。