一位 45 歲患有廣泛性焦慮症的個案，來到診所表示出現心悸、冒冷汗及瀕死感。護理師應優先採取哪項措施？
A 45-year-old client with a history of generalized anxiety disorder presents to the clinic reporting palpitations, diaphoresis, and a sense of impending doom. Which action should the nurse take first?
- AEncourage the client to practice deep breathing exercises鼓勵病人練習深呼吸運動
- BRefer the client to a psychiatric provider將病人轉介至精神科醫師
- CAssess the client's vital signs and physical status✓ 正解評估病人的生命徵象與身體狀況
- DAdminister an as-needed benzodiazepine給予按需使用的苯二氮平類藥物
面對焦慮症狀，護理評估的首要黃金定律是排除生理因素。儘管個案有焦慮症病史，但心悸、冒冷汗及瀕死感同時也是心肌梗塞、甲狀腺風暴或心律不整等致命生理問題的典型表現。護理師絕對不能因為診斷標籤（Diagnosis Labeling）而忽略了生理異常的可能性。護理處置流程必須遵循 ABC 原則（Airway, Breathing, Circulation），先測量生命徵象（Vital Signs）以穩定個案並釐清現況，若評估結果生命徵象穩定，再進一步執行心理支持與焦慮減緩的措施。這項動作反映了護理師在面對精神健康個案時，必須同時具備生理評估的敏銳度，保障病人安全。
When evaluating anxiety symptoms, the cardinal rule of nursing assessment is to rule out physiologic causes first. Although the client has a history of anxiety disorder, palpitations, diaphoresis, and a sense of impending doom are also classic findings of life-threatening conditions such as myocardial infarction, thyroid storm, or dysrhythmias. The nurse must not overlook potential physical abnormalities because of diagnostic labeling. Nursing care should follow the ABC (airway, breathing, circulation) framework, beginning with vital signs to stabilize the client and clarify the situation, and only then proceed to emotional support and anxiety-reducing interventions if vital signs are stable. This action reflects the nurse's responsibility to remain physiologically vigilant when caring for psychiatric clients in order to protect their safety.
美國護理師在執行心電圖（ECG）或測量生命徵象時擁有較大的執行彈性，可依據評估結果自行啟動急救流程；台灣護理師在急診或門診遇到類似狀況，通常會依據醫囑執行，較少在未通知醫師前自行決定檢查項目，強調團隊協作。