— 心理社會完整性 · EASY · MCQ —
一位 45 歲廣泛性焦慮症病史的個案，出現心跳加速、顫抖及瀕死感。護理師應優先採取的介入措施為何？
A 45-year-old client with a history of generalized anxiety disorder presents with rapid heart rate, tremors, and a sense of impending doom. Which intervention is the highest priority for the nurse?
- AEncourage the client to discuss the source of their anxiety鼓勵病人討論其焦慮的來源
- BInstruct the client to breathe into a paper bag指示病人用紙袋呼吸
- CAdminister an as-needed dose of alprazolam給予處方劑量的阿普唑侖（alprazolam）
- DRemain with the client and maintain a calm, quiet environment✓ 正解陪伴病人並維持安靜平和的環境
— Explanation · 中文詳解 —
面對急性焦慮或恐慌發作的個案，護理師的存在提供安全感（Presence）是首要任務。營造冷靜、低刺激的環境有助於降低個案的喚起狀態。給予藥物需醫囑，且在急性期優先處理的是安全感與減輕環境刺激，而非藥物治療。探討焦慮源通常在個案平靜後進行。
The highest priority is to remain with the client and maintain a calm, quiet environment to provide safety and reduce stimulation. This non-pharmacological approach helps lower anxiety levels immediately. Paper bag breathing is contraindicated due to hypoxia risks, and exploring anxiety sources is deferred until the client is stable.
✦ 台美臨床差異
美台護理教育均強調心理支持的重要性，但在繁忙的臨床環境下，保持陪伴的落實程度一致性較高。