一位 45 歲有廣泛性焦慮症病史的個案，主訴心悸、出汗及瀕死感。護理師的首要護理措施為何？
A 45-year-old client with a history of generalized anxiety disorder presents to the clinic reporting heart palpitations, sweating, and a feeling of impending doom. Which intervention is the highest priority for the nurse?
- AExplore the psychosocial stressors leading to the anxiety探討導致焦慮的心理社會壓力源
- BAdminister the prescribed PRN anxiolytic medication給予處方之備用抗焦慮藥物
- CConduct a thorough mental status examination進行全面的精神狀態檢查
- DInstruct the client to breathe deeply and slowly✓ 正解指示個案深呼吸並放慢速度
面對急性焦慮症狀，首要目標是穩定生理反應並幫助個案重獲掌控感。深呼吸是一種簡單、非侵入性且能立即活化副交感神經系統的方法，能有效對抗交感神經亢進帶來的身體不適。焦慮會造成過度換氣，進而引發頭暈和麻木，深呼吸能矯正此生理狀態。藥物（B）雖能緩解症狀但有鎮靜副作用且需時發揮作用，評估（C）和病因分析（A）在病人情緒穩定後進行更具效益。護理師應先採取『安全第一』的原則，以最直接的方式減輕病人的急性痛苦，建立治療性關係的基礎，而非急於藥物介入。
In acute anxiety, the priority is to stabilize the physiological response and help the client regain a sense of control. Deep breathing is a simple, noninvasive method that immediately activates the parasympathetic nervous system and effectively counteracts the somatic discomfort produced by sympathetic overactivation. Anxiety often causes hyperventilation, which in turn produces dizziness and numbness; deep breathing corrects this physiological state. Medication (B) can relieve symptoms but causes sedation and takes time to take effect; assessment (C) and exploration of stressors (A) are more useful once the client is emotionally stable. The nurse should adopt a 'safety first' approach, alleviate the client's acute distress in the most direct way, and establish the foundation for a therapeutic relationship rather than rushing to pharmacologic intervention.
美國護理師在執行深呼吸指導時，常配合引導式想像或認知行為技巧；台灣臨床環境中，對於焦慮急性發作，護理師較常傾向依賴醫囑給予抗焦慮藥物，對於非藥物處置的衛教自主性較受限。