一位 28 歲廣泛性焦慮症個案至門診表示有恐懼的生理症狀。護理師應優先評估下列何項發現？
A 28-year-old client with generalized anxiety disorder presents to the clinic reporting physical symptoms of fear. Which assessment finding should the nurse prioritize?
- AIrritability and restlessness易怒與躁動
- BDifficulty concentrating on tasks難以集中注意力於任務上
- CExcessive verbalization of worries過度表達擔憂
- DPalpitations and chest tightness✓ 正解心悸與胸悶
護理師在面對焦慮症個案時，必須優先應用 ABC（Airway, Breathing, Circulation）原則。心悸與胸悶雖然可能是焦慮的生理表現，但這些症狀同時也是心肌梗塞或心律不整的潛在徵兆。為了確保病人的生命安全，護理師必須先排除器質性（Physical）的生命威脅，確認生命徵象穩定，才能轉向心理層面的焦慮干預。
When caring for a client with anxiety, the nurse must apply the ABC (airway, breathing, circulation) principle first. Palpitations and chest tightness may be physiologic manifestations of anxiety, but they are also potential signs of myocardial infarction or arrhythmia. To ensure patient safety, the nurse must first rule out organic, life-threatening conditions and confirm that vital signs are stable before turning to psychologic anxiety interventions.