一位腫瘤診所護理師正在運用護理過程來管理一位 35 歲、新確診早期乳癌的女性病患。這位病患安靜地坐著，緊緊抓著她的皮包，兩眼發直地盯著牆壁。根據護理過程的步驟，護理師第一件該做的事情為何？
An oncology clinic nurse is utilizing the nursing process to manage a 35-year-old female client newly diagnosed with early-stage breast cancer. The client sits quietly, gripping her purse tightly, and stares blankly at the wall. According to the nursing process, what should the nurse do first?
- ARefer the client instantly to an external psychosocial support group specializing in coping mechanisms for young cancer survivors.立即將個案轉介給專門協助年輕癌症倖存者應對機制的外部心理社會支持團體。
- BAsk an open-ended question to assess the client's current emotional state and specific understanding of her new diagnosis.✓ 正解提出開放式問題以評估個案目前的情緒狀態及其對新診斷的具體理解。
- CInitiate comprehensive educational teaching regarding the diverse cosmetic options for post-mastectomy breast reconstruction surgery.針對乳房重建手術後多樣化的美容選項，開始全面的衛教。
- DReassure the client cheerfully that early-stage breast cancer has incredibly high survival rates and she has absolutely nothing to worry about.愉悅地安慰個案，表示早期乳癌的存活率極高，她絕對無需擔心。
本題測驗護理過程 (Nursing process: Assessment) 與治療性溝通。無論病患的情境多麼複雜或悲傷，護理過程的永遠第一步是『評估 (Assess)』。當病患剛收到癌症宣判且表現出呆滯、緊抓物品（休克、否認或極度焦慮的肢體語言）時，護理師不能預設病患需要什麼。立刻轉介團體（選項 A）或開始衛教重建手術（選項 C）都屬於「介入 (Intervention)」的範圍。如果在病患恐慌發作時塞一堆衛教資訊，病患根本無法吸收，這是無效的照護。最佳的起始點是使用開放式溝通技巧（例如：『妳現在感覺到了什麼？』或是『對於剛才的診斷，妳理解了多少？』）來實際「評估」病患的情緒與需求（選項 B 正確）。選項 D 給予「保證你會沒事 (False reassurance)」是治療性溝通中的絕對禁忌，這會阻斷病患真實傾訴恐懼的意願。
According to the nursing process, assessment is the first step; therefore, the nurse should use open-ended questions to evaluate the client's emotional state and understanding of the diagnosis. Interventions like referrals or teaching should follow assessment, and false reassurance is contraindicated as it blocks therapeutic communication.
治療性溝通與護理過程結合。台灣與美國護理教育皆強調「ADPIE (評估>診斷>計畫>介入>評值)」。第一步永遠選「評估(Assess)」或「問開放式問題(Open-ended question)」。不可給 False reassurance。