— 心理社會完整性 · EASY · MCQ —
一名 28 歲患有廣泛性焦慮症的個案至診所就診，主訴心悸與出汗。護理師應優先評估什麼？
A 28-year-old client with a history of generalized anxiety disorder presents to the clinic reporting heart palpitations and sweating. What should the nurse assess first?
- AThe client's coping mechanisms病人的應對機制
- BThe client's recent stressors病人的近期壓力源
- CThe client's medication adherence病人的用藥依從性
- DThe client's physical symptoms for organic causes✓ 正解病人的生理症狀以排除器質性原因
— Explanation · 中文詳解 —
面對焦慮症狀，必須先排除器質性疾患。心悸與出汗可能是甲狀腺功能亢進、心律不整或其他身體疾病的表現。在確定無生理問題前，不應直接歸因於焦慮發作。先處理 ABC 與生理需求是護理的基本原則，確保個案安全。
Physical symptoms such as palpitations and sweating may indicate underlying organic conditions like hyperthyroidism or arrhythmias rather than solely anxiety. Nursing assessment must prioritize ruling out physiological causes to ensure patient safety before attributing symptoms to a psychosocial exacerbation. Stabilizing physiological integrity is the primary step before addressing coping mechanisms or stressors.
✦ 台美臨床差異
美台護理教育均強調先排除生理原因，但在台灣診所情境下，護理師常需更主動協助醫師進行初步身體評估。