— 心理社會完整性 · EASY · MCQ —
一位 35 歲廣泛性焦慮症病史的個案，出現呼吸急促、心跳過速及瀕死感。護理師首要的介入措施為何？
A 35-year-old client with a history of generalized anxiety disorder presents with rapid breathing, tachycardia, and a sense of impending doom. What is the priority nursing intervention?
- AInstruct the client to breathe into a paper bag指示個案用紙袋呼吸
- BTeach the client about anxiety-reducing breathing techniques教導個案關於減輕焦慮的呼吸技巧
- CAdminister an as-needed dose of benzodiazepine給予處方劑量的苯二氮平類藥物
- DRemain with the client and maintain a calm, quiet environment✓ 正解留在個案身邊並維持安靜、平靜的環境
— Explanation · 中文詳解 —
面對恐慌發作的病人，陪伴與提供安全感是最優先的護理目標。建立安靜的環境有助於降低外部刺激，減緩交感神經過度興奮。紙袋呼吸法已被現代醫學淘汰，因有缺氧風險。藥物給予需醫師醫囑，衛教技巧則應在病人焦慮水平降低後進行。
During a panic attack, presence and providing safety are the top priorities. A calm, quiet environment reduces external stimuli and dampens sympathetic overactivation. Paper-bag breathing has been abandoned in modern medicine due to hypoxia risk. Medication requires a provider's order, and teaching techniques should occur after anxiety subsides.
✦ 台美臨床差異
美台護理臨床對於恐慌處置皆強調陪伴與環境，但台灣臨床多有護理師主動給予抗焦慮藥物的較嚴謹醫囑限制。