一名 25 歲患有廣泛性焦慮症的個案因心悸與顫抖至診所求診。護理師應採取的第一項行動為何？
A 25-year-old client with a history of generalized anxiety disorder presents to the clinic with palpitations and trembling. Which initial action should the nurse take?
- AInstruct the client to perform deep breathing exercises指導病人進行深呼吸練習
- BEncourage the client to ventilate feelings鼓勵病人抒發感受
- CAssess the client for physiological triggers✓ 正解評估病人是否有生理性誘發因子
- DAdminister an ordered benzodiazepine給予處方之苯二氮平類藥物
在護理評估中，面對具有已知精神疾病病史的個案，護理師必須秉持「生理優先」的臨床思考原則（Safety/ABCs）。心悸（palpitations）與顫抖（trembling）雖然常與焦慮相關，但也可能是甲狀腺機能亢進、心律不整、低血糖或藥物副作用等生理問題的表現。若未排除生理性病因即將其歸類為單純焦慮，可能導致誤診或延誤治療。因此，護理師應先進行生理評估，確認生命徵象與潛在誘發因子，確保個案安全後，再執行心理支持或焦慮緩解技巧。
In nursing assessment, when caring for a client with a known psychiatric history, the nurse must apply the principle of 'physiology first' (safety/ABCs). Palpitations and trembling are frequently associated with anxiety, but they may also reflect physiologic problems such as hyperthyroidism, dysrhythmia, hypoglycemia, or medication side effects. Categorizing them simply as anxiety without ruling out physiologic causes may lead to misdiagnosis or delayed treatment. Therefore, the nurse should first perform a physiologic assessment, verify vital signs and potential triggers, and ensure the client's safety before providing emotional support or anxiety-reduction techniques.