— 心理社會完整性 · MEDIUM · MCQ —
一位 45 歲患有廣泛性焦慮症的病人，在走廊哭泣並來回踱步，表示感覺即將失去對一切的控制。護理師優先採取的介入措施為何？
A 45-year-old client with a history of generalized anxiety disorder is crying and pacing in the hallway. The client states, 'I feel like I am going to lose control of everything.' Which nursing intervention is the highest priority?
- ATeach the client deep breathing techniques for relaxation教導病人深呼吸技巧以放鬆
- BProvide a safe, quiet environment to reduce sensory stimulation✓ 正解提供安全、安靜的環境以降低感官刺激
- CAdminister an as-needed dose of an antianxiety medication給予適量使用的抗焦慮藥物
- DEncourage the client to express their underlying fears in detail鼓勵病人詳細表達其潛在的恐懼
— Explanation · 中文詳解 —
面對處於高度焦慮或恐慌狀態的病人，降低環境刺激是首要任務。過多的感官輸入會加劇病人的混亂與失控感，提供安靜且安全的空間有助於穩定情緒，後續再進行溝通或衛教。探索細節或教導技巧在病人情緒過度激動時效果有限。
Reducing environmental stimuli is the priority intervention for a client experiencing severe anxiety or panic, as excessive sensory input can worsen feelings of loss of control. Providing a quiet, safe space helps the client regain composure before attempting communication or teaching.
✦ 台美臨床差異
美台兩地護理師對處理危機性焦慮的流程一致，皆重視先穩定環境與病人安全，再進行後續評估。