— 心理社會完整性 · EASY · MCQ —
一位患有廣泛性焦慮症的 45 歲病人出現心悸和顫抖，並表示「我覺得我快死了」。護理師應優先採取什麼行動？
A 45-year-old client with a history of generalized anxiety disorder presents with reports of palpitations and trembling. The client states, 'I feel like I am going to die.' What is the nurse's priority action?
- AAsk the client to describe the feelings in detail請病人詳細描述感受
- BAdminister the prn sedative medication給予備用鎮靜藥物
- CInstruct the client to breathe slowly with the nurse✓ 正解指導病人與護理師一起緩慢呼吸
- DPerform a comprehensive physical assessment進行全面的身體評估
— Explanation · 中文詳解 —
面對急性驚恐發作的病人，首要目標是穩定情緒和生理反應。指導深呼吸能啟動副交感神經，幫助病人重新獲得對身體的控制感，進而緩解過度換氣及焦慮症狀。藥物給予雖有效，但非第一順位處置；詳盡病史評估或身體檢查在病人極度焦慮時難以配合，且無法即時緩解症狀。
The priority action is to instruct the client to breathe slowly with the nurse, as deep breathing activates the parasympathetic nervous system to reduce acute anxiety symptoms. Probing feelings or performing a comprehensive assessment during a crisis can escalate anxiety, while medication is secondary to immediate non-pharmacological stabilization.
✦ 台美臨床差異
美台護理臨床皆強調減壓技術。台灣常態下會較快尋求藥物處置，而美國護理師更傾向於先嘗試行為引導技巧。