— 心理社會完整性 · EASY · MCQ —
一位 25 歲患有廣泛性焦慮症的個案至門診，主訴心悸、冒汗及瀕死感。護理師應優先採取何種措施？
A 25-year-old client with a history of generalized anxiety disorder presents to the clinic reporting heart palpitations, sweating, and a feeling of impending doom. Which action should the nurse take first?
- AAssess physical symptoms to rule out medical emergencies✓ 正解評估生理症狀以排除醫療急症
- BInstruct the client to practice deep breathing exercises指示個案練習深呼吸運動
- CAdminister a prescribed PRN anxiolytic medication給予處方 PRN 抗焦慮藥物
- DEncourage the client to discuss the stressors causing the anxiety鼓勵個案討論引起焦慮的壓力源
— Explanation · 中文詳解 —
在護理評估中，護理師必須遵循「生理優先（Physiological priority）」原則。焦慮症個案主訴心悸、冒汗與瀕死感，雖可能是恐慌發作（Panic attack），但這些症狀與心肌梗塞、心律不整或甲狀腺機能亢進極為相似。在未排除致命性生理狀況前，不可直接將其歸因於心理焦慮。護理師應先測量生命徵象並進行快速身體評估，確保生命穩定。
Although the client has a history of anxiety, symptoms like palpitations, sweating, and a sense of impending doom can mimic life-threatening conditions such as myocardial infarction or arrhythmias. The nurse must first assess physical symptoms and vital signs to rule out medical emergencies before attributing the presentation to a panic attack.