— 心理社會完整性 · MEDIUM · MCQ —
一位 45 歲患有廣泛性焦慮症的個案，主訴心悸、出汗及瀕死感。護理師應採取的第一優先介入措施為何？
A 45-year-old client with a history of generalized anxiety disorder presents with reports of palpitations, sweating, and feelings of impending doom. Which intervention is the nurse's initial priority?
- AEncourage the client to discuss the source of anxiety鼓勵病人討論焦慮來源
- BAdminister an as-needed benzodiazepine給予處方之苯二氮平類藥物（as-needed benzodiazepine）
- CStay with the client and provide a calm, safe environment✓ 正解陪伴病人並提供安靜、安全之環境
- DPerform a comprehensive head-to-toe physical assessment執行全面性的頭到腳身體評估
— Explanation · 中文詳解 —
面對焦慮發作（尤其是恐慌發作）的個案，建立安全感與給予支持是首要目標。護理師應維持冷靜，陪伴在案主身邊，透過低刺激的環境降低其焦慮程度。藥物給予與深入探討焦慮源屬於後續處置，而身體評估雖重要，但優先級低於確保案主的情緒穩定與安全。
During an acute panic attack, the nurse's priority is to ensure the client's safety and reduce anxiety by staying with them and providing a calm, reassuring presence. Directly exploring the cause of anxiety or administering medication before stabilization can increase distress, while a full physical assessment should not interrupt immediate emotional support.
✦ 台美臨床差異
美方護理師在心理衛生照護中具有極高的獨立處置權；台灣護理師通常需醫師評估並開立抗焦慮藥物醫囑。