— 心理社會完整性 · EASY · MCQ —
一位 45 歲患有廣泛性焦慮症的病人前來門診，主訴心悸、顫抖與瀕死感。護理師應採取的第一項優先措施為何？
A 45-year-old client with a history of generalized anxiety disorder presents to the clinic complaining of palpitations, trembling, and a sense of impending doom. What is the nurse's priority intervention?
- AInstruct the client to focus on their surroundings指示病人專注於周遭環境
- BTeach the client deep breathing exercises教導病人深呼吸練習
- CStay with the client and maintain a calm environment✓ 正解陪伴病人並維持安靜的環境
- DAdminister an ordered PRN anxiolytic給予處方上的按需（PRN）抗焦慮藥物
— Explanation · 中文詳解 —
面對急性焦慮發作（acute anxiety attack），護理師的首要任務是確保病人的安全並降低焦慮水平。根據 NCLEX 的 ABC 原則（Safety 為首），陪伴病人能提供心理支持，防止病人因恐慌而發生意外；同時，維持冷靜的環境能減少外界刺激，防止焦慮進一步升級。藥物治療或認知介入（如呼吸訓練）應在病人情緒穩定後再進行，因為在恐慌狀態下，病人無法專注於複雜指令。
During an acute anxiety attack, the nurse's priority is to stay with the client and maintain a calm environment to provide safety and prevent escalation. Direct presence offers immediate psychological support, whereas interventions like breathing exercises or medication administration are more effective once the client's anxiety level has decreased.