— 心理社會完整性 · MEDIUM · MCQ —
一位患有創傷後壓力症候群（PTSD）的個案表示：「每次聽到巨大的聲響，我就覺得自己又回到戰場上。」護理師優先採取的介入措施為何？
A client with post-traumatic stress disorder (PTSD) mentions, 'I feel like I am back in the war every time I hear a loud noise.' Which nursing intervention is the priority?
- AEncourage the client to avoid all loud noise sources.鼓勵個案避免所有巨大噪音來源
- BProvide a grounding technique to bring the client back to the present.✓ 正解提供接地技巧以幫助個案回到當下
- CExplain to the client that the sound is harmless.向個案解釋該聲音是無害的
- DRefer the client to a psychologist for deep trauma processing.將個案轉介給心理師進行深度創傷處理
— Explanation · 中文詳解 —
個案出現閃回（flashback）症狀，優先護理目標為恢復現實感。接地技巧（grounding technique）如觸摸物品或描述環境，能幫助個案脫離創傷回憶回到當下。C 選項無法改變個案知覺；D 選項為後續治療而非急性期優先處理；A 選項為消極防避，長期反而加重恐懼。
The client is experiencing flashbacks, a dissociative symptom where they feel re-experiencing the trauma. The priority nursing intervention is to use grounding techniques to help the client reconnect with the present reality and reduce acute distress.
✦ 台美臨床差異
美國對於災難或創傷後的護理介入有標準化團體心理支持課程；台灣目前 PTSD 的長期追蹤與護理介入資源相對集中於精神專科醫院。