— 心理社會完整性 · MEDIUM · MCQ —
一名 45 歲患有廣泛性焦慮症的病人，出現呼吸急促、顫抖及瀕死感。護理師首要採取的干預措施為何？
A 45-year-old client with a history of generalized anxiety disorder presents with rapid breathing, trembling, and a feeling of impending doom. Which intervention is most appropriate for the nurse to implement initially?
- AAdminister the prescribed PRN anxiolytic medication immediately立即給予處方之備用抗焦慮藥物
- BRemain with the client and maintain a calm, quiet environment✓ 正解陪伴病人並維持安靜平和的環境
- CInstruct the client to breathe into a paper bag指導病人向紙袋內呼吸
- DEncourage the client to discuss the source of their anxiety鼓勵病人討論焦慮的來源
— Explanation · 中文詳解 —
急性焦慮發作時，病人的自我控制能力下降。護理師應提供安全、安靜的環境，並全程陪伴以降低病人的不安全感，此為危機處置的核心。使用紙袋已不再建議，因可能導致缺氧；立即給藥需先評估有無醫囑且需嘗試非藥物治療無效後；詢問原因會增加病人的認知負荷，非急性期首選。
During an acute anxiety or panic attack, the client's ability to process information is impaired. The nurse should remain with the client to provide reassurance and maintain a calm, quiet environment to reduce stimulation. This supportive presence helps stabilize the client before considering pharmacological interventions or deeper discussion.
✦ 台美臨床差異
美國護理師在處理急性焦慮時較強調環境與行為介入；台灣臨床常見先給予抗焦慮藥物以縮短病房躁動時間。