一名 45 歲患有廣泛性焦慮症的個案因心悸與呼吸困難求診。護理師首要介入措施為何？
A 45-year-old client with a history of generalized anxiety disorder presents with reports of palpitations and shortness of breath. Which nursing intervention is the highest priority?
- APerform a comprehensive head-to-toe physical assessment進行全面性的頭到腳身體評估
- BInstruct the client to breathe into a paper bag指示個案使用紙袋呼吸
- CAdminister an PRN anti-anxiety medication給予處方之備用抗焦慮藥物
- DStay with the client and use a calm, firm voice✓ 正解陪伴個案並使用平靜、堅定的語調
面對焦慮發作的病人，建立安全感與降低環境刺激是首要任務。陪伴並以平靜語氣引導可減緩恐慌升級。A 為過時作法，易導致二氧化碳過高；B 在未評估前不可輕易給藥；D 在急性恐慌期間並非最優先，應先處理心理與生理穩定。
The highest priority for a client experiencing acute anxiety or panic is to establish safety and reduce environmental stimuli through therapeutic presence. Staying with the client and using a calm, firm voice helps stabilize their emotional state, whereas paper bag breathing is contraindicated due to the risk of respiratory acidosis and medication administration is secondary to immediate psychological support.
美方強調 therapeutic use of self；台灣臨床常因病床數限制較難長時間陪伴，多由家屬協助。