— 心理社會完整性 · EASY · MCQ —
一位 28 歲廣泛性焦慮症患者至診所主訴心悸與呼吸困難。哪項護理措施是最高優先級？
A 28-year-old client with generalized anxiety disorder presents to the clinic reporting palpitations and shortness of breath. Which nursing intervention is the highest priority?
- AEncourage the client to discuss the source of anxiety鼓勵病人討論焦慮的來源
- BAdminister an PRN anxiolytic medication給予 PRN 抗焦慮藥物
- CTeach the client deep breathing techniques教導病人深呼吸技巧
- DAssess the client for physiological causes of symptoms✓ 正解評估病人症狀的生理原因
— Explanation · 中文詳解 —
當病人主訴焦慮症狀（如心悸、呼吸困難）時，護理師必須秉持「生理優先（Physical before Psychological）」的原則。雖然病人有廣泛性焦慮症病史，但這些症狀同樣可能是嚴重內科疾病（如心律不整、甲狀腺亢進、肺栓塞）的表現。護理師的首要行動是進行生理評估，排除器質性病變，確保病人安全，之後才能處理心理焦慮。
Physiological stability takes priority over psychological concerns; therefore, the nurse must first assess for organic causes of palpitations and dyspnea, such as arrhythmias or pulmonary embolism. Only after ruling out physical pathology should interventions for anxiety be implemented.