— 心理社會完整性 · MEDIUM · MCQ —
一位 45 歲患有廣泛性焦慮症的病人，因心悸、盜汗及瀕死感急診入院。護理師應優先採取的措施為何？
A 45-year-old client with a history of generalized anxiety disorder is admitted to the emergency department experiencing palpitations, diaphoresis, and a feeling of impending doom. Which intervention is the highest priority for the nurse?
- AInstruct the client to breathe deeply and slowly✓ 正解指示客戶深呼吸並放慢速度
- BEncourage the client to discuss the stressors causing the anxiety鼓勵客戶討論引起焦慮的壓力源
- CPerform a comprehensive physical assessment進行全面的身體評估
- DAdminister an as-needed dose of an anxiolytic medication給予處方備用的抗焦慮藥物劑量
— Explanation · 中文詳解 —
面對焦慮急性發作時，降低呼吸頻率能啟動副交感神經系統，促進生理放鬆。優先穩定生理反應是護理的第一步，過度換氣會加劇身體不適，穩定呼吸有助於緩解急迫感。其他選項如給藥或深度心理探討，均需在急性壓力緩解後再進行。
During an acute anxiety attack, the priority is to help the client regain physiological control by slowing the respiratory rate to activate the parasympathetic nervous system. Non-pharmacological interventions like deep breathing should be attempted first to reduce immediate symptoms before considering medication or exploring underlying stressors.
✦ 台美臨床差異
美國護理常強調先提供引導呼吸等非藥物介入；台灣臨床常規較傾向先給予安眠鎮靜藥物以求速效。