一位 35 歲、患有廣泛性焦慮症的個案，出現呼吸急促、心悸及強烈的瀕死感。護理師應採取的第一優先行動為何？
A 35-year-old client with a history of generalized anxiety disorder presents with rapid breathing, heart palpitations, and a sense of impending doom. What is the nurse's priority action?
- AEncourage the client to talk about the source of anxiety鼓勵個案談論焦慮的來源
- BAdminister the prescribed PRN anxiolytic給予處方之備用抗焦慮藥物
- CTeach the client deep breathing exercises教導個案深呼吸運動
- DStay with the client and use a calm, low-pitched voice✓ 正解陪伴個案並使用平靜、低沉的語調
面對急性焦慮發作，首要任務是提供情緒支持與安全感。護理師應留在個案身邊，以平穩、低沉的聲音引導情緒平復，避免因護理師焦慮感染個案。B選項為藥物介入，需先嘗試非藥物治療；A選項在急性發作期，個案難以理性分析原因；C選項需在個案情緒稍平靜後才有效。
During an acute panic attack, the client is physiologically aroused and unable to process complex cognitive information, making verbal analysis or teaching ineffective at that moment. The priority nursing action is to provide a safe, reassuring presence by staying with the client and using a calm, low-pitched voice to help reduce anxiety intensity and prevent feelings of abandonment.
美台護理臨床皆強調 therapeutic presence 的重要性，但在藥物給予上，台灣需醫師開立醫囑後執行，美國部分情境下可依據 standing orders 處理。